Healthcare Provider Details

I. General information

NPI: 1467016246
Provider Name (Legal Business Name): TICORA ELIZABETH MARABLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 HOLME AVE
PHILADELPHIA PA
19152
US

IV. Provider business mailing address

1329 ROTHLEY AVE
ABINGTON PA
19001-2414
US

V. Phone/Fax

Practice location:
  • Phone: 215-335-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP018549
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP018549
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberSP018549
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP018549
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: