Provider Demographics
NPI:1770128159
Name:MENTZ, CHRISTINE ANN
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:MENTZ
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 1:13903 ASCOT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1603
Mailing Address - Country:US
Mailing Address - Phone:904-304-2447
Mailing Address - Fax:
Practice Address - Street 1:13903 ASCOT DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1603
Practice Address - Country:US
Practice Address - Phone:904-304-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL19000184766374U00000X, 311ZA0620X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No253Z00000XAgenciesIn Home Supportive Care