Healthcare Provider Details

I. General information

NPI: 1104869254
Provider Name (Legal Business Name): MONICA MORTENSEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY NEMOURS CHILDRENS CLINIC, JACKSONVILLE
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-697-3792
Mailing address:
  • Phone: 302-651-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS10132
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number036-111969
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberOS10132
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: