Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | CNP-01858 | NM |
NPI | 1013284777 |
---|---|
Provider Name | Mrs. Polly Anne Hickman |
First Address | Alamogordo, NM 88310-8700 |
Second Address | Alamogordo, NM 88310-8700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/11/2011 |
Last Update Date | 31/01/2012 |