Provider Demographics
NPI:1255617973
Name:SANCILLO TICE, SHELIA A (CFNP)
Entity type:Individual
Prefix:MRS
First Name:SHELIA
Middle Name:A
Last Name:SANCILLO TICE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:SHELIA
Other - Middle Name:A
Other - Last Name:SANCILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:456 W BANKHEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3319
Mailing Address - Country:US
Mailing Address - Phone:662-534-8780
Mailing Address - Fax:662-314-8577
Practice Address - Street 1:456 W BANKHEAD ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3319
Practice Address - Country:US
Practice Address - Phone:662-534-8780
Practice Address - Fax:662-314-8577
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857901363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01484713Medicaid