Provider Demographics
NPI:1194463570
Name:MEAD, DOMINIQUE SHAYRAE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SHAYRAE
Last Name:MEAD
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 1:10252 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9277
Mailing Address - Country:US
Mailing Address - Phone:810-730-9531
Mailing Address - Fax:
Practice Address - Street 1:10252 STANLEY RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9277
Practice Address - Country:US
Practice Address - Phone:810-730-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703123669164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse