Provider Demographics
NPI:1972937597
Name:FAH, MONIQUE KENIEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:KENIEN
Last Name:FAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:NADINE
Other - Last Name:KENIEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 4477
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91617-0477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26665 SEAGULL WAY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4547
Practice Address - Country:US
Practice Address - Phone:818-667-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14749TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist