Provider Demographics
NPI:1811238652
Name:HICKERSON, LATIA MICHELLE (WHNP)
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:MICHELLE
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:LATIA
Other - Middle Name:MICHELLE
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:17000 EL CAMINO REAL
Mailing Address - Street 2:STE 209
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2633
Mailing Address - Country:US
Mailing Address - Phone:832-930-6345
Mailing Address - Fax:
Practice Address - Street 1:17000 EL CAMINO REAL
Practice Address - Street 2:STE 209
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2633
Practice Address - Country:US
Practice Address - Phone:832-930-6345
Practice Address - Fax:281-754-4903
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX794027207V00000X, 363L00000X
TXAP122845363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology