Provider Demographics
NPI:1215520291
Name:LUMPKIN, MONIQUE CHEVETTE (CA5633)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:CHEVETTE
Last Name:LUMPKIN
Suffix:
Gender:F
Credentials:CA5633
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-2133
Mailing Address - Country:US
Mailing Address - Phone:951-545-8624
Mailing Address - Fax:
Practice Address - Street 1:4505 ALLSTATE DR STE 208
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1779
Practice Address - Country:US
Practice Address - Phone:951-545-8624
Practice Address - Fax:844-746-7646
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA5633207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty