Provider Demographics
NPI:1043337496
Name:FORD, MONIQUE LA VETTE (RN)
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:LA VETTE
Last Name:FORD
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 1:5351 GLEN CANYON RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5866
Mailing Address - Country:US
Mailing Address - Phone:419-450-9811
Mailing Address - Fax:
Practice Address - Street 1:5351 GLEN CANYON RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5866
Practice Address - Country:US
Practice Address - Phone:419-450-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN278711163WH0200X
NC230578163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2408102Medicaid