Provider Demographics
NPI:1144709312
Name:WALTERS SMITH, MONQUENETTE VESHA
Entity type:Individual
Prefix:
First Name:MONQUENETTE
Middle Name:VESHA
Last Name:WALTERS SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONQUENETTE
Other - Middle Name:VESHA
Other - Last Name:WALTERS SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:216 W HARDING WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5607
Mailing Address - Country:US
Mailing Address - Phone:209-456-4697
Mailing Address - Fax:
Practice Address - Street 1:216 W HARDING WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5607
Practice Address - Country:US
Practice Address - Phone:209-456-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK2615641744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30-0730025Medicaid