Provider Demographics
NPI:1629396866
Name:MONBRUN, MINETRICIA (BA)
Entity Type:Individual
Prefix:
First Name:MINETRICIA
Middle Name:
Last Name:MONBRUN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 SAINT JOHNS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1844
Mailing Address - Country:US
Mailing Address - Phone:904-389-5231
Mailing Address - Fax:904-677-8019
Practice Address - Street 1:4570 SAINT JOHNS AVE STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1844
Practice Address - Country:US
Practice Address - Phone:904-389-5231
Practice Address - Fax:904-677-8019
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL360358001Medicaid