Provider Demographics
NPI:1457081507
Name:DOMINIQUE, WOODLY TERRY
Entity Type:Individual
Prefix:
First Name:WOODLY
Middle Name:TERRY
Last Name:DOMINIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 TALLOKAS RD
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-7666
Mailing Address - Country:US
Mailing Address - Phone:615-935-8357
Mailing Address - Fax:
Practice Address - Street 1:2050 TALLOKAS RD
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-7666
Practice Address - Country:US
Practice Address - Phone:615-935-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty