Provider Demographics
NPI:1184799413
Name:TICE, DONNA MARIE (APRN BC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:TICE
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:PETRILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10 REGENT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-925-7795
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVENUE
Practice Address - Street 2:VETERAN'S ADMINISTRATION MEDICAL CENTER
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003511363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health