Provider Demographics
NPI:1740629591
Name:TICE, AMANDA SHAY (ACNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHAY
Last Name:TICE
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SHAY
Other - Last Name:MEDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:1000 HOUSTON STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:817-336-0551
Mailing Address - Fax:817-339-3940
Practice Address - Street 1:1000 HOUSTON STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-336-0551
Practice Address - Fax:817-339-3940
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX703553363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care