Provider Demographics
NPI:1609658509
Name:COLEMAN, DOMINIQUE D (CNA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:D
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 HOLSCHER RD UNIT 110
Mailing Address - Street 2:
Mailing Address - City:MCFARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8453
Mailing Address - Country:US
Mailing Address - Phone:608-512-3069
Mailing Address - Fax:
Practice Address - Street 1:5607 HOLSCHER RD UNIT 110
Practice Address - Street 2:
Practice Address - City:MCFARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-8453
Practice Address - Country:US
Practice Address - Phone:608-512-3069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI031968601779374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide