1265475081 NPI number — MRS. MARIAELENA ELEANORA TICE RN, CPNP

Table of content: MRS. MARIAELENA ELEANORA TICE RN, CPNP (NPI 1265475081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265475081 NPI number — MRS. MARIAELENA ELEANORA TICE RN, CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TICE
Provider First Name:
MARIAELENA
Provider Middle Name:
ELEANORA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265475081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4777 GUB CLUB ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-553-2750
Provider Business Mailing Address Fax Number:
254-285-6193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
C THOMAS MOORE HEALTH CLINIC
Provider Second Line Business Practice Location Address:
56TH AND 761ST BATTALION AVE BUILDING 2245
Provider Business Practice Location Address City Name:
FORT HOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-4752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-553-2750
Provider Business Practice Location Address Fax Number:
254-285-6193
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  449918 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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