Provider Demographics
NPI:1043738362
Name:ANCRUM, MONE
Entity Type:Individual
Prefix:
First Name:MONE
Middle Name:
Last Name:ANCRUM
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 1:4245 WINDALE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6869
Mailing Address - Country:US
Mailing Address - Phone:678-777-2665
Mailing Address - Fax:404-393-0686
Practice Address - Street 1:4245 WINDALE DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6869
Practice Address - Country:US
Practice Address - Phone:678-777-2665
Practice Address - Fax:404-393-0686
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier