Provider Demographics
NPI:1497351241
Name:TICE, CASSANDRA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LYNN
Last Name:TICE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CANANDAIGUA ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1326
Mailing Address - Country:US
Mailing Address - Phone:315-597-6609
Mailing Address - Fax:315-597-3898
Practice Address - Street 1:120 CANANDAIGUA ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1326
Practice Address - Country:US
Practice Address - Phone:315-597-6609
Practice Address - Fax:315-597-3898
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY733896163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse