Healthcare Provider Details

I. General information

NPI: 1235855685
Provider Name (Legal Business Name): MRS. TAMICA D RHODES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMICA D PETTIGREW

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 MEDICAL CENTER DR STE 102
ORANGE CITY FL
32763-8225
US

IV. Provider business mailing address

1061 MEDICAL CENTER DR STE 102
ORANGE CITY FL
32763-8225
US

V. Phone/Fax

Practice location:
  • Phone: 386-456-3852
  • Fax: 833-972-5940
Mailing address:
  • Phone: 386-456-3852
  • Fax: 833-972-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number221924
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: