Provider Demographics
NPI:1114348620
Name:DOMINIQUE, SARAH E (APN CDE)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:APN CDE
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:E
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 FLOSSMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-624-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010901364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics