Provider Demographics
NPI:1508359233
Name:FAM-NAKHLA, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:FAM-NAKHLA
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 1:809 PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5639
Mailing Address - Country:US
Mailing Address - Phone:321-401-7026
Mailing Address - Fax:321-401-7026
Practice Address - Street 1:809 PATRICK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5639
Practice Address - Country:US
Practice Address - Phone:321-401-7026
Practice Address - Fax:321-401-7026
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020524500Medicaid