=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659664134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE LEANNE BALDY HICKS CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 07/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 19TH ST S
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35233-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-975-3107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 DEBRA AVE
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-566-6911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 9315696
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1-074196
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------