Provider Demographics
NPI:1679963250
Name:FUENTES, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:FUENTES
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 1:310 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-5123
Mailing Address - Country:US
Mailing Address - Phone:517-667-4271
Mailing Address - Fax:
Practice Address - Street 1:310 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:POTTERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48876-5123
Practice Address - Country:US
Practice Address - Phone:517-667-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111808164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse