Healthcare Provider Details

I. General information

NPI: 1750272001
Provider Name (Legal Business Name): MS. NOELA J MOMBURI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 SALISBURY RD STE 220
JACKSONVILLE FL
32256-0959
US

IV. Provider business mailing address

7733 PARADISE ISLAND BLVD APT 2510
JACKSONVILLE FL
32256-3779
US

V. Phone/Fax

Practice location:
  • Phone: 877-844-0053
  • Fax: 904-900-2224
Mailing address:
  • Phone: 904-881-7005
  • Fax: 904-900-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW22063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: