Provider Demographics
NPI:1225713829
Name:MCLAUGHLIN, DOMINIQUE EBONIECE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:EBONIECE
Last Name:MCLAUGHLIN
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 1:21701 PARTHENIA ST APT 308
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2451
Mailing Address - Country:US
Mailing Address - Phone:917-932-7378
Mailing Address - Fax:
Practice Address - Street 1:19500 NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1108
Practice Address - Country:US
Practice Address - Phone:866-365-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2023006023363LF0000X
CA95026260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily