Provider Demographics
NPI:1851345144
Name:WILLIAMS HICKMAN, SALLY ANN (RN, CS-FNP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:WILLIAMS HICKMAN
Suffix:
Gender:F
Credentials:RN, CS-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 KENTUCKY AENUE
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775
Mailing Address - Country:US
Mailing Address - Phone:417-256-9111
Mailing Address - Fax:417-255-9732
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2029
Practice Address - Country:US
Practice Address - Phone:417-256-9111
Practice Address - Fax:417-255-9732
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO599022307Medicaid
MO427376405Medicaid
MO599022308Medicaid
MO427376405Medicaid
MO599022307Medicaid
S96538Medicare UPIN
MO000014537Medicare ID - Type UnspecifiedCARE PROFESSIONAL