Provider Demographics
NPI:1114543980
Name:MILESTONES PEDIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:MILESTONES PEDIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:HATCHER
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:601-990-4028
Mailing Address - Street 1:224 S CHURCH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3232
Mailing Address - Country:US
Mailing Address - Phone:601-990-4028
Mailing Address - Fax:
Practice Address - Street 1:224 S CHURCH ST STE B
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3232
Practice Address - Country:US
Practice Address - Phone:601-990-4028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008700082Medicaid