Provider Demographics
NPI:1295499937
Name:MONA, MAGAN (NP-C)
Entity type:Individual
Prefix:
First Name:MAGAN
Middle Name:
Last Name:MONA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4015
Mailing Address - Country:US
Mailing Address - Phone:904-355-6583
Mailing Address - Fax:904-683-4064
Practice Address - Street 1:710 LOMAX ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4015
Practice Address - Country:US
Practice Address - Phone:904-355-6583
Practice Address - Fax:904-683-4064
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016629363LF0000X
FLRN9423072163WU0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WU0100XNursing Service ProvidersRegistered NurseUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL460772206Medicaid
FL460772206OtherINSURERS