Healthcare Provider Details

I. General information

NPI: 1043337496
Provider Name (Legal Business Name): MONIQUE LA VETTE FORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5351 GLEN CANYON RD
RALEIGH NC
27616-5866
US

IV. Provider business mailing address

5351 GLEN CANYON RD
RALEIGH NC
27616-5866
US

V. Phone/Fax

Practice location:
  • Phone: 419-450-9811
  • Fax:
Mailing address:
  • Phone: 419-450-9811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN278711
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number230578
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: