Provider Demographics
NPI:1861948150
Name:MONROE, RACQUEL (FNP)
Entity type:Individual
Prefix:
First Name:RACQUEL
Middle Name:
Last Name:MONROE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:RACQUEL
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5010 STATE HIGHWAY 30 STE 205
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7532
Mailing Address - Country:US
Mailing Address - Phone:518-842-2663
Mailing Address - Fax:518-842-4861
Practice Address - Street 1:434 S KINGSBORO AVE STE 102
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-3822
Practice Address - Country:US
Practice Address - Phone:518-773-4242
Practice Address - Fax:518-773-4246
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340964363LF0000X
NY340964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049750Medicaid