Provider Demographics
NPI:1073129342
Name:ALLEN, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:ALLEN
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 1:203 S LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3423
Mailing Address - Country:US
Mailing Address - Phone:478-304-6005
Mailing Address - Fax:
Practice Address - Street 1:203 S LANCASTER ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3423
Practice Address - Country:US
Practice Address - Phone:478-304-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002474225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant