Provider Demographics
NPI:1609640341
Name:OBIA, MONCELLA BURCH
Entity Type:Individual
Prefix:
First Name:MONCELLA
Middle Name:BURCH
Last Name:OBIA
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 1:750 E MID CITIES BLVD APT 1404
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4667
Mailing Address - Country:US
Mailing Address - Phone:972-513-5273
Mailing Address - Fax:
Practice Address - Street 1:750 E MID CITIES BLVD APT 1404
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-4667
Practice Address - Country:US
Practice Address - Phone:972-513-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage