Provider Demographics
NPI:1760021703
Name:BEMBRY, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BEMBRY
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 1:5750 ABBEY DR APT 4M
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2532
Mailing Address - Country:US
Mailing Address - Phone:314-280-1004
Mailing Address - Fax:
Practice Address - Street 1:552 N MANNHEIM RD STE B
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1121
Practice Address - Country:US
Practice Address - Phone:314-280-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-21
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000000000OtherN/A