Healthcare Provider Details

I. General information

NPI: 1477650497
Provider Name (Legal Business Name): MONIQUE LILLIAN MARIE LEVESQUE-HARTLE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 CONSTITUTION DRIVE
FORT WAYNE IN
46804
US

IV. Provider business mailing address

6320 CONSTITUTION DRIVE
FORT WAYNE IN
46804
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-7339
  • Fax:
Mailing address:
  • Phone: 260-432-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number08001638
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number3169
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number3054
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: