Provider Demographics
NPI:1437698032
Name:LADD, DOMANIQUE L
Entity Type:Individual
Prefix:MS
First Name:DOMANIQUE
Middle Name:L
Last Name:LADD
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 1:87 FIR ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1706
Mailing Address - Country:US
Mailing Address - Phone:708-830-5320
Mailing Address - Fax:
Practice Address - Street 1:87 FIR ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1706
Practice Address - Country:US
Practice Address - Phone:708-830-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No174400000XOther Service ProvidersSpecialist