Provider Demographics
NPI:1881430163
Name:TICKNOR, MARY (DNAP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:DNAP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SANTELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 S TORREY PINE LN
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-7649
Mailing Address - Country:US
Mailing Address - Phone:605-929-3633
Mailing Address - Fax:
Practice Address - Street 1:910 E 20TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1012
Practice Address - Country:US
Practice Address - Phone:605-334-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCR001191367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered