Provider Demographics
NPI:1679118525
Name:HICKS HOME-BASED PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:HICKS HOME-BASED PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, DNP
Authorized Official - Phone:251-408-7568
Mailing Address - Street 1:1111 E I65 SERVICE RD S STE 210
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-3123
Mailing Address - Country:US
Mailing Address - Phone:251-408-7568
Mailing Address - Fax:
Practice Address - Street 1:1111 E I65 SERVICE RD S STE 210
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-3123
Practice Address - Country:US
Practice Address - Phone:251-408-7568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-14
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1033206545OtherBC/BS
AL1033206545OtherPRIVATE INSURANCES
AL1033206545Medicaid
AL1033206545OtherUNITED HEALTH