Provider Demographics
NPI:1477888790
Name:HICKMAN, TRACEY QUAY (FNP, APMHNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:QUAY
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:FNP, APMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FOOTE ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-4834
Mailing Address - Country:US
Mailing Address - Phone:662-287-4424
Mailing Address - Fax:
Practice Address - Street 1:601 FOOTE ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-4834
Practice Address - Country:US
Practice Address - Phone:662-287-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-04
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR782227363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily