Provider Demographics
NPI:1558527911
Name:HICKMAN, LATOSHA DAWN
Entity type:Individual
Prefix:MISS
First Name:LATOSHA
Middle Name:DAWN
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-6833
Mailing Address - Country:US
Mailing Address - Phone:618-796-0025
Mailing Address - Fax:
Practice Address - Street 1:1101 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4815
Practice Address - Country:US
Practice Address - Phone:918-426-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100742400FMedicaid
OK100742400BMedicaid
OK100742400DMedicaid