Healthcare Provider Details

I. General information

NPI: 1376799684
Provider Name (Legal Business Name): MONIQUE F FUENTES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 12/19/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMELLIA AT DEERWOOD 10061 SWEETWATER PARKWAY
JACKSONVILLE FL
32256-3225
US

IV. Provider business mailing address

1501 WINSTON LN
FLEMING ISLAND FL
32003-7400
US

V. Phone/Fax

Practice location:
  • Phone: 904-519-1034
  • Fax:
Mailing address:
  • Phone: 904-635-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT11535
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT008398
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: