Provider Demographics
NPI:1508562562
Name:CORRELL, DOMONIQUE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:CORRELL
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 1:4334 RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-1830
Mailing Address - Country:US
Mailing Address - Phone:504-564-5440
Mailing Address - Fax:
Practice Address - Street 1:4747 EARHART BLVD STE G
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-1747
Practice Address - Country:US
Practice Address - Phone:504-731-1607
Practice Address - Fax:504-910-3065
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator