Provider Demographics
NPI:1053958264
Name:MONTICONE, TRACY LYNN (RN)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNN
Last Name:MONTICONE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13442 TEDDINGTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5873
Mailing Address - Country:US
Mailing Address - Phone:904-612-4848
Mailing Address - Fax:
Practice Address - Street 1:7011 A C SKINNER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6954
Practice Address - Country:US
Practice Address - Phone:904-612-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9429731163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, AmbulatoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1Medicaid