Provider Demographics
NPI:1740670322
Name:TANKSLEY, MONIQUE
Entity type:Individual
Prefix:MISS
First Name:MONIQUE
Middle Name:
Last Name:TANKSLEY
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 1:2233 UPTON DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1186
Mailing Address - Country:US
Mailing Address - Phone:757-430-5101
Mailing Address - Fax:757-430-5111
Practice Address - Street 1:2233 UPTON DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-1186
Practice Address - Country:US
Practice Address - Phone:757-430-5101
Practice Address - Fax:757-430-5111
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230017226183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician