Provider Demographics
NPI:1477295640
Name:POISSON, MONIQUE ROSE (FNP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:ROSE
Last Name:POISSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1412
Mailing Address - Country:US
Mailing Address - Phone:603-769-9549
Mailing Address - Fax:
Practice Address - Street 1:3665 S 8400 W
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-4907
Practice Address - Country:US
Practice Address - Phone:801-250-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12134797-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily