Provider Demographics
NPI:1669649570
Name:HICKORY FLAT FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:HICKORY FLAT FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:GOSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-202-5685
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:HICKORY FLAT
Mailing Address - State:MS
Mailing Address - Zip Code:38633-0128
Mailing Address - Country:US
Mailing Address - Phone:662-333-6387
Mailing Address - Fax:
Practice Address - Street 1:250 OAK STREET
Practice Address - Street 2:
Practice Address - City:HICKOR FLAT
Practice Address - State:MS
Practice Address - Zip Code:38633
Practice Address - Country:US
Practice Address - Phone:662-333-6378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR687235261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care