Provider Demographics
NPI:1265475081
Name:TICE, MARIAELENA ELEANORA (RN, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MARIAELENA
Middle Name:ELEANORA
Last Name:TICE
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 GUB CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76501
Mailing Address - Country:US
Mailing Address - Phone:254-553-2750
Mailing Address - Fax:254-285-6193
Practice Address - Street 1:C THOMAS MOORE HEALTH CLINIC
Practice Address - Street 2:56TH AND 761ST BATTALION AVE BUILDING 2245
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-4752
Practice Address - Country:US
Practice Address - Phone:254-553-2750
Practice Address - Fax:254-285-6193
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX449918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner