| Doctor Name: | MONIQUE MANDERSON |
| NPI Number: | 1619360070 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | NP-C |
| License Number: | 209012605 |
| Business Practice Address: | 2001 State St East Saint Louis, IL - 622051803 |
| Business Phone Number: | 6182719191 |
| Business Fax Number: | 6182719617 |
| Mailing Address: | 2001 State St, EAST SAINT LOUIS |
| State: | IL |
| Postal Code: | 622051803 |
| Phone Number: | 6182719191 |
| Fax Number: | 6182719617 |
| NPI Enumeration Date: | 03/10/2015 |
| NPI Last Update Date: | 03/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 209012605 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |