Healthcare Provider Details

I. General information

NPI: 1578061438
Provider Name (Legal Business Name): MIDWIFE HOPE TERRELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4714 BIRKENHEAD RD
JACKSONVILLE FL
32210-4138
US

IV. Provider business mailing address

4714 BIRKENHEAD RD
JACKSONVILLE FL
32210-4138
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-3697
  • Fax: 904-339-9011
Mailing address:
  • Phone: 904-450-3697
  • Fax: 904-339-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number210
License Number StateFL

VIII. Authorized Official

Name: DAFFINI HOPE TERRELL
Title or Position: OWNER
Credential: LM,CPM
Phone: 904-476-2999