Provider Demographics
NPI:1790188605
Name:MONTIQUE, MONIFA
Entity Type:Individual
Prefix:
First Name:MONIFA
Middle Name:
Last Name:MONTIQUE
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:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0505
Mailing Address - Country:US
Mailing Address - Phone:229-432-1440
Mailing Address - Fax:
Practice Address - Street 1:806 14TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1394
Practice Address - Country:US
Practice Address - Phone:229-888-4093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2013016513363LF0000X
GARN205498363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily