Healthcare Provider Details

I. General information

NPI: 1407203235
Provider Name (Legal Business Name): CHRISTINA TICE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 DUNWOODY PARK SUITE 100
ATLANTA GA
30338-7408
US

IV. Provider business mailing address

5780 PEACHTREE DUNWOODY RD SUITE 300
ATLANTA GA
30342-1554
US

V. Phone/Fax

Practice location:
  • Phone: 770-730-0451
  • Fax: 770-730-0141
Mailing address:
  • Phone: 404-303-1224
  • Fax: 404-303-1325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN109252
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: