Healthcare Provider Details

I. General information

NPI: 1215474580
Provider Name (Legal Business Name): MONIQUE A DRAKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MONIQUE ANDREA RAYMOND

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LIVEWELL DR
KENNEBUNK ME
04043-6762
US

IV. Provider business mailing address

2 LIVEWELL DR
KENNEBUNK ME
04043-6762
US

V. Phone/Fax

Practice location:
  • Phone: 207-467-8550
  • Fax: 207-467-8551
Mailing address:
  • Phone: 207-467-8550
  • Fax: 207-467-8551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0684
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2807
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114205
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: