Provider Demographics
NPI:1932933108
Name:WEATHERSPOON, AMERICA MONIQUE
Entity type:Individual
Prefix:
First Name:AMERICA
Middle Name:MONIQUE
Last Name:WEATHERSPOON
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 1:13740 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-9001
Mailing Address - Country:US
Mailing Address - Phone:352-800-1054
Mailing Address - Fax:
Practice Address - Street 1:13740 ADAMS ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32735-9001
Practice Address - Country:US
Practice Address - Phone:352-800-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities