Provider Demographics
NPI:1073644282
Name:TICE, NANCY ELLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:ELLEN
Last Name:TICE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:ELLEN
Other - Last Name:TICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1955 MERRICK RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4642
Mailing Address - Country:US
Mailing Address - Phone:516-849-4985
Mailing Address - Fax:516-867-0503
Practice Address - Street 1:1955 MERRICK RD
Practice Address - Street 2:STE 106
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4615
Practice Address - Country:US
Practice Address - Phone:516-849-4985
Practice Address - Fax:516-867-0503
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1887092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01989880Medicaid