Provider Demographics
NPI:1396326997
Name:MONGNO, CHRISTOPHER NICHOLAS
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:NICHOLAS
Last Name:MONGNO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 EDGE PARK TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-1921
Mailing Address - Country:US
Mailing Address - Phone:631-672-7493
Mailing Address - Fax:
Practice Address - Street 1:50 PLAZA DR STE 104
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8549
Practice Address - Country:US
Practice Address - Phone:386-447-5447
Practice Address - Fax:386-447-5502
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant