Provider Demographics
NPI:1245937630
Name:MAVOUR, MONIQUE
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:
Last Name:MAVOUR
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 1:4303 WALIS PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-5748
Mailing Address - Country:US
Mailing Address - Phone:561-320-6071
Mailing Address - Fax:
Practice Address - Street 1:4303 WALIS PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-5748
Practice Address - Country:US
Practice Address - Phone:561-320-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
177F00000XOther177F00000X