Provider Demographics
NPI:1134100753
Name:TICE, KYLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KYLEEN
Middle Name:
Last Name:TICE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KYLEEN
Other - Middle Name:
Other - Last Name:BRONNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 DEFENSE HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8902
Mailing Address - Country:US
Mailing Address - Phone:667-204-7000
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PKWY STE 400
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:443-481-6515
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16645225100000X
MD22230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68414Medicare ID - Type Unspecified