Healthcare Provider Details

I. General information

NPI: 1184016842
Provider Name (Legal Business Name): SECONDRIA MONIQUE WASHINGTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SECONDRIA MONIQUE HENRY

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 08/23/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 UNION AVE.
MEMPHIS TN
38174-0010
US

IV. Provider business mailing address

5774 BEDFORD LOOP E
SOUTHAVEN MS
38672-7533
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2410
  • Fax: 901-261-6010
Mailing address:
  • Phone: 662-719-0973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR882517
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19798
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: