Provider Demographics
NPI:1962747071
Name:LATHAM-HICKMAN, JENNIVIE SHAUNETTE (FAMILY NP)
Entity type:Individual
Prefix:
First Name:JENNIVIE
Middle Name:SHAUNETTE
Last Name:LATHAM-HICKMAN
Suffix:
Gender:F
Credentials:FAMILY NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:101 WESTOVER CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-4900
Mailing Address - Country:US
Mailing Address - Phone:256-461-0209
Mailing Address - Fax:256-325-3147
Practice Address - Street 1:101 WESTOVER CIR
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-4900
Practice Address - Country:US
Practice Address - Phone:256-461-0209
Practice Address - Fax:256-325-3147
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-098043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL148215Medicaid