Healthcare Provider Details

I. General information

NPI: 1780503516
Provider Name (Legal Business Name): XIII MOONS APOTHECARY & FUNCTIONAL WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 MONCRIEF RD STE 8
JACKSONVILLE FL
32209-2564
US

IV. Provider business mailing address

6050 MONCRIEF RD STE 8
JACKSONVILLE FL
32209-2564
US

V. Phone/Fax

Practice location:
  • Phone: 904-551-0110
  • Fax:
Mailing address:
  • Phone: 904-551-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KENYA BONNER
Title or Position: FOUNDER & CEO
Credential:
Phone: 904-631-4801