MEDICARE: CHRISTINA TICE CNM

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	367A00000X	Advanced Practice Midwife	RN109252	GA

General Provider Information

NPI Number	:	1407203235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA TICE CNM

Provider Business Mailing Address
First Line	:	5780 PEACHTREE DUNWOODY RD
Second Line	:	SUITE 300
City	:	ATLANTA
State	:	GA
Zip	:	30342-1554
Country	:	US
Telephone Number	:	404-303-1224
Fax Number	:	404-303-1325

Provider Business Practice Location Address
First Line	:	11 DUNWOODY PARK
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30338-7408
Country	:	US
Telephone Number	:	770-730-0451
Fax Number	:	770-730-0141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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