Provider Demographics
NPI:1184016842
Name:WASHINGTON, SECONDRIA MONIQUE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SECONDRIA
Middle Name:MONIQUE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SECONDRIA
Other - Middle Name:MONIQUE
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5774 BEDFORD LOOP E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7533
Mailing Address - Country:US
Mailing Address - Phone:662-719-0973
Mailing Address - Fax:
Practice Address - Street 1:1520 UNION AVE.
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38174-0010
Practice Address - Country:US
Practice Address - Phone:901-276-2410
Practice Address - Fax:901-261-6010
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882517363LF0000X
TN19798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024911Medicaid
MS06556734Medicaid