Provider Demographics
NPI:1700343811
Name:HICKENBOTTOM, LATRICIA DELORIS (CRNP)
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:DELORIS
Last Name:HICKENBOTTOM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3581 MEADOW LN E
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 S UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-2958
Practice Address - Country:US
Practice Address - Phone:251-343-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-134340363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology