Healthcare Provider Details

I. General information

NPI: 1912732462
Provider Name (Legal Business Name): TICE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 BYRD DR
LOVELAND CO
80538-7198
US

IV. Provider business mailing address

3983 EUCALYPTUS ST
WELLINGTON CO
80549-2038
US

V. Phone/Fax

Practice location:
  • Phone: 970-593-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number1684303
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: