Provider Demographics
NPI:1235595141
Name:SPEAKS, DOMINIQUE SOPHIA DESTINY (FNP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SOPHIA DESTINY
Last Name:SPEAKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1362
Practice Address - Street 1:652 N MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7008
Practice Address - Country:US
Practice Address - Phone:843-432-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily