Provider Demographics
NPI:1891059721
Name:TICKLE, MARY K (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:TICKLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:BENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:610 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2589
Mailing Address - Country:US
Mailing Address - Phone:276-525-1550
Mailing Address - Fax:276-525-1609
Practice Address - Street 1:610 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2589
Practice Address - Country:US
Practice Address - Phone:276-525-1550
Practice Address - Fax:276-525-1609
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001188554163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse