Provider Demographics
NPI:1497539787
Name:MORTEZAI, MONDONA MONICA
Entity Type:Individual
Prefix:
First Name:MONDONA
Middle Name:MONICA
Last Name:MORTEZAI
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 1:13019 CORDELIA LN UNIT 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5166
Mailing Address - Country:US
Mailing Address - Phone:561-523-1302
Mailing Address - Fax:
Practice Address - Street 1:14185 LAKE NONA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-7421
Practice Address - Country:US
Practice Address - Phone:407-816-8064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS66079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist