Provider Demographics
NPI:1114325875
Name:DOMINIQUE, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DOMINIQUE
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 1:57 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2208
Mailing Address - Country:US
Mailing Address - Phone:631-672-1832
Mailing Address - Fax:
Practice Address - Street 1:6321 NEW UTRECHT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5425
Practice Address - Country:US
Practice Address - Phone:212-687-7464
Practice Address - Fax:212-257-7016
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320688-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse