Provider Demographics
NPI:1972878049
Name:MOOREHEAD, MONIQUE ANTOINETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:ANTOINETTE
Last Name:MOOREHEAD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 RUGBY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1135
Mailing Address - Country:US
Mailing Address - Phone:585-410-9685
Mailing Address - Fax:
Practice Address - Street 1:53 RUGBY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1135
Practice Address - Country:US
Practice Address - Phone:585-410-9685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280383164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse