Provider Demographics
NPI:1073655726
Name:TICKLE, KAYNELL (BS)
Entity Type:Individual
Prefix:
First Name:KAYNELL
Middle Name:
Last Name:TICKLE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 FOX TOWN RD
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-7006
Mailing Address - Country:US
Mailing Address - Phone:276-926-8603
Mailing Address - Fax:
Practice Address - Street 1:138 PARK PLACE
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-1684
Practice Address - Fax:276-926-6070
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator