Provider Demographics
NPI:1598255655
Name:MEDINA-DOBBS, MONICA (390200000X)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MEDINA-DOBBS
Suffix:
Gender:F
Credentials:390200000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N INDIGO TER
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4465
Mailing Address - Country:US
Mailing Address - Phone:904-413-3360
Mailing Address - Fax:
Practice Address - Street 1:12443 SAN JOSE BLVD STE 403
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8650
Practice Address - Country:US
Practice Address - Phone:904-413-3360
Practice Address - Fax:904-703-7839
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 390200000X
FLND10018133N00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program