Healthcare Provider Details

I. General information

NPI: 1558810309
Provider Name (Legal Business Name): JAMES HODGE AG-ANCP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

2609 AMATI DRIVE
KISSIMMEE FL
34741
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-4225
  • Fax:
Mailing address:
  • Phone: 410-608-5376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP9461696
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberLP-0000348
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR192286
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number008372
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN9461696
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: