Provider Demographics
NPI:1538356779
Name:WELBECK, MONIQUE T (NP)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:T
Last Name:WELBECK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-924-2254
Mailing Address - Fax:718-442-0189
Practice Address - Street 1:235 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-924-2254
Practice Address - Fax:718-442-0189
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY534142-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357451Medicaid