MEDICARE: MRS. MARIAELENA ELEANORA TICE RN, CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	449918	TX

General Provider Information

NPI Number	:	1265475081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIAELENA ELEANORA TICE RN, CPNP

Provider Business Mailing Address
First Line	:	4777 GUB CLUB ROAD
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76501
Country	:	US
Telephone Number	:	254-553-2750
Fax Number	:	254-285-6193

Provider Business Practice Location Address
First Line	:	C THOMAS MOORE HEALTH CLINIC
Second Line	:	56TH AND 761ST BATTALION AVE BUILDING 2245
City	:	FORT HOOD
State	:	TX
Zip	:	76544-4752
Country	:	US
Telephone Number	:	254-553-2750
Fax Number	:	254-285-6193

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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