Provider Demographics
NPI:1932735727
Name:HICKMAN, TYRAH PATRICE (NP)
Entity Type:Individual
Prefix:MS
First Name:TYRAH
Middle Name:PATRICE
Last Name:HICKMAN
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 1:1825 S NORRELL RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-3103
Mailing Address - Country:US
Mailing Address - Phone:601-473-6441
Mailing Address - Fax:
Practice Address - Street 1:3450 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-7201
Practice Address - Country:US
Practice Address - Phone:601-473-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903798363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health