MEDICARE: MALLORIE MICHELLE MONK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1003179516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORIE MICHELLE MONK

Provider Business Mailing Address
First Line	:	4904 CANADIAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2218
Country	:	US
Telephone Number	:	702-526-9908
Fax Number	:

Provider Business Practice Location Address
First Line	:	4904 CANADIAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2218
Country	:	US
Telephone Number	:	702-526-9908
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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Directions to “ MALLORIE MICHELLE MONK ” Practice Location

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