Provider Demographics
NPI:1164154548
Name:CHAMBLISS, MONIQUE R
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:R
Last Name:CHAMBLISS
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 1:4410 TOWNSHIP LINE RD APT C4
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4139
Mailing Address - Country:US
Mailing Address - Phone:215-910-9931
Mailing Address - Fax:
Practice Address - Street 1:401 S SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:CLIFTON HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:19018-2364
Practice Address - Country:US
Practice Address - Phone:267-595-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACO2794331744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty