Provider Demographics
NPI:1396360087
Name:SMALLWOOD, DOMINIQUE FELICE (LMP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:FELICE
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17015 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8722
Mailing Address - Country:US
Mailing Address - Phone:253-343-7586
Mailing Address - Fax:
Practice Address - Street 1:17015 4TH AVE S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8722
Practice Address - Country:US
Practice Address - Phone:253-343-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61043254225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist