Provider Demographics
NPI:1245889963
Name:BALLARD, MONIQUE JANAY
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:JANAY
Last Name:BALLARD
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 1:3418 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-3061
Mailing Address - Country:US
Mailing Address - Phone:330-953-9017
Mailing Address - Fax:
Practice Address - Street 1:940 PLAZAVIEW CT BLDG M
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-3316
Practice Address - Country:US
Practice Address - Phone:330-746-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0209195253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care