Healthcare Provider Details

I. General information

NPI: 1093862179
Provider Name (Legal Business Name): CAMILLE MARIE TICHENOR R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 GEYSER RD
BALLSTON SPA NY
12020
US

IV. Provider business mailing address

25 STEWART DAM RD
CORINTH NY
12822-2721
US

V. Phone/Fax

Practice location:
  • Phone: 518-885-6884
  • Fax: 518-885-0077
Mailing address:
  • Phone: 518-885-6884
  • Fax: 518-885-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number523847-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: