Healthcare Provider Details

I. General information

NPI: 1871196337
Provider Name (Legal Business Name): SONIA BAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SE MONTEREY COMMONS BLVD STE 104
STUART FL
34996-3327
US

IV. Provider business mailing address

1000 SE MONTEREY COMMONS BLVD STE 104
STUART FL
34996-3327
US

V. Phone/Fax

Practice location:
  • Phone: 561-818-7620
  • Fax: 772-223-3639
Mailing address:
  • Phone: 561-818-7620
  • Fax: 772-223-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11003627
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11003627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: