Provider Demographics
NPI:1891261483
Name:REVLETT, MONIKA LUCILLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MONIKA
Middle Name:LUCILLE
Last Name:REVLETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MONIKA
Other - Middle Name:LUCILLE
Other - Last Name:DOMINIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1610 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4331
Mailing Address - Country:US
Mailing Address - Phone:931-624-0126
Mailing Address - Fax:
Practice Address - Street 1:1610 6TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4331
Practice Address - Country:US
Practice Address - Phone:931-624-0126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000063953164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse