Provider Demographics
NPI:1528778248
Name:PATRICK, IVESTER MONIQUE
Entity type:Individual
Prefix:
First Name:IVESTER
Middle Name:MONIQUE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 ICHABOD CIR APT 122
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4420
Mailing Address - Country:US
Mailing Address - Phone:682-241-3104
Mailing Address - Fax:
Practice Address - Street 1:3901 ICHABOD CIR APT 122
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-4420
Practice Address - Country:US
Practice Address - Phone:682-241-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19783511347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle