Provider Demographics
NPI:1992591176
Name:COOLIDGE, MONIQUE DANIELLE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:DANIELLE
Last Name:COOLIDGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MALLETTE DR
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-9528
Mailing Address - Country:US
Mailing Address - Phone:661-858-6380
Mailing Address - Fax:
Practice Address - Street 1:1300 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4199
Practice Address - Country:US
Practice Address - Phone:575-835-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine