Provider Demographics
NPI:1326416371
Name:WIGGINS, MONIQUE S
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:S
Last Name:WIGGINS
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 1:18645 DETROIT AVE
Mailing Address - Street 2:APT 702
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3276
Mailing Address - Country:US
Mailing Address - Phone:216-507-8410
Mailing Address - Fax:
Practice Address - Street 1:18645 DETROIT AVE
Practice Address - Street 2:APT 702
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3276
Practice Address - Country:US
Practice Address - Phone:216-507-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401787880915376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide