Healthcare Provider Details

I. General information

NPI: 1093375917
Provider Name (Legal Business Name): MONIQUE HERNANDEZ MADRID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26934 N 178TH AVE
SURPRISE AZ
85387-1075
US

IV. Provider business mailing address

11009 W ALMERIA RD
AVONDALE AZ
85392-5429
US

V. Phone/Fax

Practice location:
  • Phone: 623-224-1214
  • Fax:
Mailing address:
  • Phone: 602-814-7381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA11870
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: