Provider Demographics
NPI:1780361220
Name:MARTIN, MONIQUE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:
Other - Last Name:WELLWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5723
Mailing Address - Country:US
Mailing Address - Phone:734-544-3050
Mailing Address - Fax:734-544-6732
Practice Address - Street 1:2140 E ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2552
Practice Address - Country:US
Practice Address - Phone:734-544-3050
Practice Address - Fax:734-544-6732
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIW430609115711172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker