Provider Demographics
NPI:1063267235
Name:COLLEY, MONIQUE MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MICHELLE
Last Name:COLLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:MICHELLE
Other - Last Name:MCDOUGALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5913 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5510
Mailing Address - Country:US
Mailing Address - Phone:706-461-1425
Mailing Address - Fax:
Practice Address - Street 1:2199 OLD BRIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2911
Practice Address - Country:US
Practice Address - Phone:703-357-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant