Provider Demographics
NPI:1235516964
Name:TICE, JULIE M (CRNA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:TICE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MULBERRY STREET, SW
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645
Mailing Address - Country:US
Mailing Address - Phone:828-757-5965
Mailing Address - Fax:828-757-5104
Practice Address - Street 1:321 MULBERRY STREET, SW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645
Practice Address - Country:US
Practice Address - Phone:828-757-5388
Practice Address - Fax:828-757-5237
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001986367500000X
NC290785367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ53899AMedicare PIN