Provider Demographics
NPI:1962808295
Name:BENNETT FASBENDER, MONIQUE NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:NICOLE
Last Name:BENNETT FASBENDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 2ND ST
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1610
Mailing Address - Country:US
Mailing Address - Phone:608-524-4334
Mailing Address - Fax:608-524-4335
Practice Address - Street 1:251 2ND ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1610
Practice Address - Country:US
Practice Address - Phone:608-524-4334
Practice Address - Fax:608-524-4335
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8606T152W00000X, 152WC0802X
WI3667-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3667-35OtherWISCONSIN OPTOMETRIC LICENSE
TX8606TOtherTEXAS OPTOMETRIC LICENSE