Provider Demographics
NPI:1720131295
Name:TICKNOR, DONNA LORRAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:LORRAINE
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:408 KATHE CT
Mailing Address - Street 2:
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-1312
Mailing Address - Country:US
Mailing Address - Phone:301-996-2949
Mailing Address - Fax:619-268-5973
Practice Address - Street 1:1600 CRAIN HWY S STE 608
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6442
Practice Address - Country:US
Practice Address - Phone:410-205-9205
Practice Address - Fax:619-268-5973
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD324402084P0800X
MDD00863722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry