Provider Demographics
NPI:1164484515
Name:HICKMAN, KAWANA LATRICE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KAWANA
Middle Name:LATRICE
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100442
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-0442
Mailing Address - Country:US
Mailing Address - Phone:414-828-7202
Mailing Address - Fax:
Practice Address - Street 1:3423 N 57TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2842
Practice Address - Country:US
Practice Address - Phone:414-828-7202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302249-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse