Provider Demographics
NPI:1396023800
Name:HARRIS, DOMINIQUE NICOLE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:HARRIS
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 1:2305 W HORIZON RIDGE PKWY APT 1412
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5785
Mailing Address - Country:US
Mailing Address - Phone:310-919-8736
Mailing Address - Fax:
Practice Address - Street 1:2305 W HORIZON RIDGE PKWY APT 1412
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5785
Practice Address - Country:US
Practice Address - Phone:310-919-8736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner