Provider Demographics
NPI:1881341279
Name:TICKLE, AMBER ALEXSANDRA
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:ALEXSANDRA
Last Name:TICKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OBRIEN GLENWAY
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-9251
Mailing Address - Country:US
Mailing Address - Phone:315-529-6448
Mailing Address - Fax:
Practice Address - Street 1:22 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2452
Practice Address - Country:US
Practice Address - Phone:607-753-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program