Healthcare Provider Details

I. General information

NPI: 1962384065
Provider Name (Legal Business Name): TAIRAE DESHAUN MONROE CRANIAL PROSTHESIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6017 LAKEWAY DR
FAYETTEVILLE NC
28306-9754
US

IV. Provider business mailing address

6017 LAKEWAY DR
FAYETTEVILLE NC
28306-9754
US

V. Phone/Fax

Practice location:
  • Phone: 757-940-9878
  • Fax:
Mailing address:
  • Phone: 757-940-9878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: