Provider Demographics
NPI:1942479571
Name:TICKERHOFF, STEPHANIE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TICKERHOFF
Suffix:
Gender:F
Credentials:FNP
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-6430
Mailing Address - Fax:336-277-6448
Practice Address - Street 1:280 BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2796
Practice Address - Country:US
Practice Address - Phone:336-277-6430
Practice Address - Fax:336-277-6448
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018112084S0012X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003723Medicaid
NC340014Medicare Oscar/Certification
NC2592049AMedicare PIN
NC7003723Medicaid