Provider Demographics
NPI:1518027614
Name:HICKMAN, GLENDA FAYE HARRIS (ARNP)
Entity Type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:FAYE HARRIS
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:FAYE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:704 S HILL ST
Mailing Address - Street 2:
Mailing Address - City:TIMMONSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29161-1917
Mailing Address - Country:US
Mailing Address - Phone:864-735-4691
Mailing Address - Fax:
Practice Address - Street 1:101 WILLIAM H JOHNSON ST STE 600
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2773
Practice Address - Country:US
Practice Address - Phone:843-777-7083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA1627363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007258100Medicaid
FLY07K7OtherBLUE CROSS BLUE SHIELD
FLP00937830OtherMEDICARE RAILROAD
FLP00937830OtherMEDICARE RAILROAD
U6860YMedicare PIN
U6860YMedicare PIN