Individual
GRACE DIANA TICE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1641 TAMIAMI TRL STE 1, PORT CHARLOTTE, FL 33948-1018
(941) 629-6262
Mailing address
1235 AUGUSTA ST E, LEHIGH ACRES, FL 33974-0728
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9116492
FL
Other
Enumeration date
10/04/2022
Last updated
10/04/2022
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