Provider Demographics
NPI:1568922177
Name:WALTON, DOMINIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3548 FENLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1346
Mailing Address - Country:US
Mailing Address - Phone:216-501-8997
Mailing Address - Fax:
Practice Address - Street 1:402 GOLFVIEW LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-4414
Practice Address - Country:US
Practice Address - Phone:440-443-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.165940164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse