Provider Demographics
NPI:1477382190
Name:LICERIO, MONIQUE HOLLMANN
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:HOLLMANN
Last Name:LICERIO
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 1:3235 30TH ST APT C25
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2938
Mailing Address - Country:US
Mailing Address - Phone:347-510-4343
Mailing Address - Fax:
Practice Address - Street 1:3235 30TH ST APT C25
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2938
Practice Address - Country:US
Practice Address - Phone:347-510-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717947163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty