Provider Demographics
NPI:1700815263
Name:HICKS, KERRY (NP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7163 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1904
Mailing Address - Country:US
Mailing Address - Phone:662-895-3700
Mailing Address - Fax:662-895-4886
Practice Address - Street 1:7163 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1904
Practice Address - Country:US
Practice Address - Phone:662-895-3700
Practice Address - Fax:662-895-4886
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09809597Medicaid
LA1035971Medicaid
LA1035971Medicaid
MSQ53542Medicare UPIN
MS09809597Medicaid
MSP00398931Medicare PIN