Provider Demographics
NPI:1376989640
Name:DOMINIQUE, CLAUDETTE MARCIA (RN)
Entity Type:Individual
Prefix:MS
First Name:CLAUDETTE
Middle Name:MARCIA
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 OHIO AVE
Mailing Address - Street 2:BAYSHORE,NY
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5215
Mailing Address - Country:US
Mailing Address - Phone:631-665-1949
Mailing Address - Fax:
Practice Address - Street 1:1376 OHIO AVE
Practice Address - Street 2:BAYSHORE
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5215
Practice Address - Country:US
Practice Address - Phone:631-665-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8068345163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse