Provider Demographics
NPI:1194443952
Name:HODGE, TAMIKO LATIESE (OWNER)
Entity type:Individual
Prefix:
First Name:TAMIKO
Middle Name:LATIESE
Last Name:HODGE
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3911
Mailing Address - Country:US
Mailing Address - Phone:863-241-6590
Mailing Address - Fax:
Practice Address - Street 1:1425 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3911
Practice Address - Country:US
Practice Address - Phone:863-241-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker