Provider Demographics
NPI:1578032934
Name:NEELY, DOMINIQUE LAMONT
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LAMONT
Last Name:NEELY
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:PO BOX 9610
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-0610
Mailing Address - Country:US
Mailing Address - Phone:757-969-3250
Mailing Address - Fax:
Practice Address - Street 1:4410 CLAIBORNE SQ E STE 334
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2074
Practice Address - Country:US
Practice Address - Phone:757-966-7066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)