Basic Information
| Provider Information | |||||||||
| NPI: | 1811550031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKMON | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAYTON | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1509 DULLES DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705063718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 SW 8TH ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727127886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2019 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A006183 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.