Provider Demographics
NPI:1295098085
Name:TICE, KELLUM ROBERT (NP)
Entity type:Individual
Prefix:
First Name:KELLUM
Middle Name:ROBERT
Last Name:TICE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2767
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:21214 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-3373
Practice Address - Country:US
Practice Address - Phone:832-912-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX730287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner