Healthcare Provider Details

I. General information

NPI: 1205450954
Provider Name (Legal Business Name): MONIQUE D GAY HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 FAVOR RD SW # 1G06
MARIETTA GA
30060-5241
US

IV. Provider business mailing address

PO BOX 1244
SMYRNA GA
30081-1244
US

V. Phone/Fax

Practice location:
  • Phone: 678-468-9702
  • Fax:
Mailing address:
  • Phone: 678-468-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: