Healthcare Provider Details

I. General information

NPI: 1497689509
Provider Name (Legal Business Name): MONIQUE HANNAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MONIQUE HERMAN MAIDEN NAME

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12915 FOOTHILL BLVD
RANCHO CUCAMONGA CA
91739-3930
US

IV. Provider business mailing address

12915 FOOTHILL BLVD
RANCHO CUCAMONGA CA
91739-3930
US

V. Phone/Fax

Practice location:
  • Phone: 424-383-2742
  • Fax:
Mailing address:
  • Phone: 424-383-2742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number302606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: