Basic Information
| Provider Information | |||||||||
| NPI: | 1467899211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TICE | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOSACK | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR BLDG 2600 | ||||||||
| Address2: | |||||||||
| City: | ALIQUIPPA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150012150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243044950 | ||||||||
| FaxNumber: | 4122793416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR BLDG 2600 | ||||||||
| Address2: | |||||||||
| City: | ALIQUIPPA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150012150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243044950 | ||||||||
| FaxNumber: | 4122793416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SP012800 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | SP012800 | 01 | PA | LICENSE NUMBER | OTHER | SP012800 | 05 | PA | MEDICAID |