Provider Demographics
NPI:1275289910
Name:MONGE, JULISSA
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:MONGE
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:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-0791
Mailing Address - Country:US
Mailing Address - Phone:141-354-0110
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLE ST STE 301
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2223
Practice Address - Country:US
Practice Address - Phone:413-540-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program