Provider Demographics
NPI:1225893001
Name:JOHNSON, DOMINIQUE SHAKIA
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SHAKIA
Last Name:JOHNSON
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 1:21229 HILLSIDE AVE APT 7MW
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1823
Mailing Address - Country:US
Mailing Address - Phone:347-869-8952
Mailing Address - Fax:
Practice Address - Street 1:21229 HILLSIDE AVE APT 7MW
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1823
Practice Address - Country:US
Practice Address - Phone:347-869-8952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty