Provider Demographics
NPI:1376395228
Name:PRICE, DOMONIQUE LEJON
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:LEJON
Last Name:PRICE
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 1:3301 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-3605
Mailing Address - Country:US
Mailing Address - Phone:313-587-0269
Mailing Address - Fax:
Practice Address - Street 1:7663 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3210
Practice Address - Country:US
Practice Address - Phone:313-721-7649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide