Provider Demographics
NPI:1477650497
Name:LEVESQUE-HARTLE, MONIQUE LILLIAN MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:LILLIAN MARIE
Last Name:LEVESQUE-HARTLE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 CONSTITUTION DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-7339
Mailing Address - Fax:
Practice Address - Street 1:6320 CONSTITUTION DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-7339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001638111NN1001X
MN3169111NN1001X
WI3054111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN668460Medicare ID - Type Unspecified
INU46597Medicare UPIN