Provider Demographics
NPI:1316355548
Name:WILKES, MONDA LEONA
Entity Type:Individual
Prefix:MRS
First Name:MONDA
Middle Name:LEONA
Last Name:WILKES
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 247592
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-7592
Mailing Address - Country:US
Mailing Address - Phone:614-323-8106
Mailing Address - Fax:
Practice Address - Street 1:3368 SUFFIELD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7530
Practice Address - Country:US
Practice Address - Phone:614-323-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2662846Medicaid