Provider Demographics
NPI:1457668238
Name:COBB, MONIQUE MISTIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MISTIQUE
Last Name:COBB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7198 LAURETTA CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5108
Mailing Address - Country:US
Mailing Address - Phone:614-589-5378
Mailing Address - Fax:
Practice Address - Street 1:7198 LAURETTA CT
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-5108
Practice Address - Country:US
Practice Address - Phone:614-589-5378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN129441164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse