Provider Demographics
NPI:1518355593
Name:MONTABON, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:MONTABON
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 1:17488 SLIPPER SHELL WAY
Mailing Address - Street 2:UNIT 15
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-6312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17488 SLIPPER SHELL WAY
Practice Address - Street 2:UNIT 15
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-6312
Practice Address - Country:US
Practice Address - Phone:856-404-2699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0044237163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse