Provider Demographics
NPI:1497572473
Name:FAYNE, MONIQUE N (OWNER OF AFH)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:N
Last Name:FAYNE
Suffix:
Gender:F
Credentials:OWNER OF AFH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 W MAYFAIR RD #13132
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-350-7570
Mailing Address - Fax:
Practice Address - Street 1:7820 W TOWNSEND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3942
Practice Address - Country:US
Practice Address - Phone:414-350-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI203801376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide