Healthcare Provider Details

I. General information

NPI: 1053958264
Provider Name (Legal Business Name): TRACY LYNN MONTICONE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 A C SKINNER PKWY
JACKSONVILLE FL
32256-6954
US

IV. Provider business mailing address

13442 TEDDINGTON LN
JACKSONVILLE FL
32226-5873
US

V. Phone/Fax

Practice location:
  • Phone: 904-612-4848
  • Fax:
Mailing address:
  • Phone: 904-612-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number9429731
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: