Provider Demographics
NPI:1508129610
Name:ELLIS, MONIQUE LYNETTE
Entity Type:Individual
Prefix:MISS
First Name:MONIQUE
Middle Name:LYNETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:LYNETTE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TEACHER
Mailing Address - Street 1:111 LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5078
Mailing Address - Country:US
Mailing Address - Phone:718-625-4055
Mailing Address - Fax:
Practice Address - Street 1:111 LIVINGSTON STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-851-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist