Provider Demographics
NPI:1578340709
Name:HICKS, KELLI M (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 COUNTY ROAD 57
Mailing Address - Street 2:
Mailing Address - City:GORDO
Mailing Address - State:AL
Mailing Address - Zip Code:35466-3844
Mailing Address - Country:US
Mailing Address - Phone:205-454-8787
Mailing Address - Fax:
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2071
Practice Address - Country:US
Practice Address - Phone:205-759-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-135782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily