Healthcare Provider Details

I. General information

NPI: 1598255655
Provider Name (Legal Business Name): MONICA MEDINA-DOBBS 390200000X
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12443 SAN JOSE BLVD STE 403
JACKSONVILLE FL
32223-8650
US

IV. Provider business mailing address

700 N INDIGO TER
ST JOHNS FL
32259-4465
US

V. Phone/Fax

Practice location:
  • Phone: 904-413-3360
  • Fax: 904-703-7839
Mailing address:
  • Phone: 904-413-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND10018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: