Provider Demographics
NPI:1750272001
Name:MOMBURI, NOELA J
Entity type:Individual
Prefix:MS
First Name:NOELA
Middle Name:J
Last Name:MOMBURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 PARADISE ISLAND BLVD APT 2510
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3779
Mailing Address - Country:US
Mailing Address - Phone:904-881-7005
Mailing Address - Fax:904-900-2224
Practice Address - Street 1:4655 SALISBURY RD STE 220
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0959
Practice Address - Country:US
Practice Address - Phone:877-844-0053
Practice Address - Fax:904-900-2224
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW220631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical