Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 08001638 | IN |
N | 111NN1001X | Nutrition | 3054 | WI |
N | 111NN1001X | Nutrition | 3169 | MN |
NPI | 1477650497 |
---|---|
Provider Name | Dr. Monique Lillian Marie Levesque-Hartle |
First Address | Fort Wayne, IN 46804 |
Second Address | Fort Wayne, IN 46804 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 17/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U46597 | (02) | IN |