MEDICARE: MIDWIFE HOPE TERRELL LLC

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	176B00000X	Midwife	210	FL

General Provider Information

NPI Number	:	1578061438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWIFE HOPE TERRELL LLC

Provider Business Mailing Address
First Line	:	4714 BIRKENHEAD RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-4138
Country	:	US
Telephone Number	:	904-450-3697
Fax Number	:	904-339-9011

Provider Business Practice Location Address
First Line	:	4714 BIRKENHEAD RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-4138
Country	:	US
Telephone Number	:	904-450-3697
Fax Number	:	904-339-9011

Authorized Official
Title or Position	:	OWNER
Name	:	DAFFINI HOPE TERRELL
Credential	:	LM,CPM
Telephone Number	:	904-476-2999

Provider Enumeration Date	:	01/25/2018
Last Update Date	:	01/25/2018

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