Provider Demographics
NPI:1497021414
Name:HICKS, LISA M (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1980
Mailing Address - Country:US
Mailing Address - Phone:334-793-1881
Mailing Address - Fax:334-340-5918
Practice Address - Street 1:126 CLINIC DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1980
Practice Address - Country:US
Practice Address - Phone:334-793-1881
Practice Address - Fax:334-340-5918
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-109237363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL196555Medicaid