Provider Demographics
NPI:1891365201
Name:MONROE, NIKKIESHA DOMINIQUE
Entity Type:Individual
Prefix:
First Name:NIKKIESHA
Middle Name:DOMINIQUE
Last Name:MONROE
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 1:1813 HENRY AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-2939
Mailing Address - Country:US
Mailing Address - Phone:330-209-9558
Mailing Address - Fax:
Practice Address - Street 1:1813 HENRY AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-2939
Practice Address - Country:US
Practice Address - Phone:330-209-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty