Healthcare Provider Details

I. General information

NPI: 1831263243
Provider Name (Legal Business Name): MONICA M IMMORDINO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BLANDING BLVD
ORANGE PARK FL
32073-2235
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 400
MIAMI FL
33126-2051
US

V. Phone/Fax

Practice location:
  • Phone: 904-773-8977
  • Fax: 904-773-8974
Mailing address:
  • Phone: 305-500-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR114730
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9426913
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN9426913
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: