Provider Demographics
NPI:1346766417
Name:VENABLE, DOMONIQUE MICHELLE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:MICHELLE
Last Name:VENABLE
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 1:1103 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2811
Mailing Address - Country:US
Mailing Address - Phone:330-559-5987
Mailing Address - Fax:
Practice Address - Street 1:1103 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-2811
Practice Address - Country:US
Practice Address - Phone:330-559-5987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant