Provider Demographics
NPI:1093798894
Name:HIGGINBOTHAM, DALE (FNP)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:DALE
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1523 22ND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4016
Mailing Address - Country:US
Mailing Address - Phone:601-703-8370
Mailing Address - Fax:855-320-7336
Practice Address - Street 1:1523 22ND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4016
Practice Address - Country:US
Practice Address - Phone:601-703-8370
Practice Address - Fax:855-320-7336
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1101944363LF0000X
MSR668885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06172593Medicaid
Q42146Medicare UPIN