Provider Demographics
NPI:1083490031
Name:HENDRICKS, DOMINIQUE S
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:S
Last Name:HENDRICKS
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:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:ANMOORE
Mailing Address - State:WV
Mailing Address - Zip Code:26323-0315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 CASINO DRIVE
Practice Address - Street 2:
Practice Address - City:ANMOORE
Practice Address - State:WV
Practice Address - Zip Code:26323
Practice Address - Country:US
Practice Address - Phone:304-622-1684
Practice Address - Fax:304-622-0810
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40469164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse