MEDICARE: MS. MONIQUE MANDERSON FNP-C, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP11235	AZ
2	363LF0000X	Family Nurse Practitioner	209012605	IL
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209012605	IL
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61438293	WA
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11014186	FL

General Provider Information

NPI Number	:	1619360070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MONIQUE MANDERSON FNP-C, PMHNP-BC

Provider Business Mailing Address
First Line	:	122 E MAIN ST STE 124
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4655
Country	:	US
Telephone Number	:	708-205-3517
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 E MAIN ST STE 124
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4655
Country	:	US
Telephone Number	:	708-205-3517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2015
Last Update Date	:	02/18/2026

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