Healthcare Provider Details

I. General information

NPI: 1427878966
Provider Name (Legal Business Name): ETHEL-SONIA TIKUM APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 AMESBURY DR APT 338
DALLAS TX
75206-4836
US

IV. Provider business mailing address

8709 63RD AVE
BERWYN HEIGHTS MD
20740-2763
US

V. Phone/Fax

Practice location:
  • Phone: 301-364-2675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1170179
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: