Provider Demographics
NPI:1164825923
Name:TICE, JOHNNY R (FNP-C)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:R
Last Name:TICE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21231
Mailing Address - Street 2:
Mailing Address - City:TISCA;PPSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401
Mailing Address - Country:US
Mailing Address - Phone:205-366-3010
Mailing Address - Fax:205-366-3012
Practice Address - Street 1:115 HARPER COURT
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1250
Practice Address - Country:US
Practice Address - Phone:205-366-3010
Practice Address - Fax:205-366-3012
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC271591363L00000X
NC5007244363LF0000X
AL1-123152363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1164825923Medicaid
NCNCL340BMedicare PIN
NCNCL340AMedicare PIN