Provider Demographics
NPI:1033507603
Name:MENDANA, DOMINIQUE MARIE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:MENDANA
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 1:306 N MAIN ST STE 1A1
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2533
Mailing Address - Country:US
Mailing Address - Phone:912-320-4573
Mailing Address - Fax:
Practice Address - Street 1:306 N MAIN ST STE 1A1
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2533
Practice Address - Country:US
Practice Address - Phone:912-320-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014102100Medicaid