Provider Demographics
NPI:1134661457
Name:WILLIAMS, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:WILLIAMS
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 1:122 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2720
Mailing Address - Country:US
Mailing Address - Phone:203-422-2129
Mailing Address - Fax:
Practice Address - Street 1:122 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2720
Practice Address - Country:US
Practice Address - Phone:203-422-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013036183500000X
NY20 062541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist