Basic Information
| Provider Information | |||||||||
| NPI: | 1669038303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSEPH | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAULK | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | ANTOINETTE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3012 NORWELL CT | ||||||||
| Address2: | |||||||||
| City: | LOCUST GROVE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302483450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042455516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3334 HIGHWAY 155 STE B | ||||||||
| Address2: | |||||||||
| City: | LOCUST GROVE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703057929 | ||||||||
| FaxNumber: | 7703057969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2019 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN170750 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | RN170750 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.