Provider Demographics
NPI:1831861798
Name:MILES, MONIQUE LAQUAN
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:LAQUAN
Last Name:MILES
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 1:4720 SALISBURY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6101
Mailing Address - Country:US
Mailing Address - Phone:352-672-1670
Mailing Address - Fax:352-631-6812
Practice Address - Street 1:4720 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:352-672-1670
Practice Address - Fax:352-631-6812
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other