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NPI Code Detail

MEDICARE: MS. MONIQUE NELLIE PROVENCIO

MEDICARE: MS. MONIQUE NELLIE PROVENCIO
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
11041C0700XClinical Social WorkerASW136999CA
21041C0700XClinical Social Worker150.118978IL

General Provider Information

NPI Number : 1346618154
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MONIQUE NELLIE PROVENCIO
Provider Business Mailing Address
First Line : 430 N PILGRIM ST
Second Line :
City : STOCKTON
State : CA
Zip : 95205-4428
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 430 N PILGRIM ST
Second Line :
City : STOCKTON
State : CA
Zip : 95205-4428
Country : US
Telephone Number : --
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/10/2015
Last Update Date : 02/11/2026

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Directions to “ MS. MONIQUE NELLIE PROVENCIO ” Practice Location

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