Provider Demographics
NPI:1174035778
Name:AGRARIAN WELLNESS, LLC
Entity Type:Organization
Organization Name:AGRARIAN WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH, APRN, WHNP
Authorized Official - Phone:832-930-6345
Mailing Address - Street 1:17000 EL CAMINO REAL STE 209
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2633
Mailing Address - Country:US
Mailing Address - Phone:832-284-4328
Mailing Address - Fax:832-284-4728
Practice Address - Street 1:17000 EL CAMINO REAL STE 209
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058
Practice Address - Country:US
Practice Address - Phone:832-284-4328
Practice Address - Fax:832-284-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-04
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WL0100X
TX363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty