Provider Demographics
NPI:1568507176
Name:SHOCKLEY, MONIQUE MARTIN
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MARTIN
Last Name:SHOCKLEY
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 1:3540 CRAIN HIGHWAY
Mailing Address - Street 2:383
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1303
Mailing Address - Country:US
Mailing Address - Phone:240-206-0621
Mailing Address - Fax:
Practice Address - Street 1:920 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2145
Practice Address - Country:US
Practice Address - Phone:202-854-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP20639208100000X
DCMD046856208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation