Provider Demographics
NPI:1407165673
Name:DOMKE, LINDY DAWN
Entity Type:Individual
Prefix:
First Name:LINDY
Middle Name:DAWN
Last Name:DOMKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDY
Other - Middle Name:DAWN
Other - Last Name:VAN MATRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2580 E JOYCE BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3924
Mailing Address - Country:US
Mailing Address - Phone:794-521-7337
Mailing Address - Fax:
Practice Address - Street 1:2580 E JOYCE BLVD #12
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-520-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2933225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214583721Medicaid