Provider Demographics
NPI:1821565094
Name:WELLS, MONIQUE L
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:L
Last Name:WELLS
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 1:5035 TALBOT PL S UNIT A
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7930
Mailing Address - Country:US
Mailing Address - Phone:206-259-1194
Mailing Address - Fax:
Practice Address - Street 1:5035 TALBOT PL S UNIT A
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-7930
Practice Address - Country:US
Practice Address - Phone:206-259-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty