Provider Demographics
NPI:1417674656
Name:HARGROVE, MYSTIQUE (MS, CFSD, CBS, CBE)
Entity Type:Individual
Prefix:
First Name:MYSTIQUE
Middle Name:
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:MS, CFSD, CBS, CBE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12753 DAYLIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8034
Mailing Address - Country:US
Mailing Address - Phone:404-901-3638
Mailing Address - Fax:
Practice Address - Street 1:12753 DAYLIGHT TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-8034
Practice Address - Country:US
Practice Address - Phone:904-510-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker