Provider Demographics
NPI:1326215070
Name:HICKERSON, MICHELLE DAWN (APN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LOMBARDY ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-3106
Mailing Address - Country:US
Mailing Address - Phone:731-855-3132
Mailing Address - Fax:731-855-3132
Practice Address - Street 1:174 MURRAY GUARD DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3742
Practice Address - Country:US
Practice Address - Phone:731-660-6168
Practice Address - Fax:731-660-6296
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000013561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner