Provider Demographics
NPI:1619348075
Name:LOISEAU, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:LOISEAU
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 1:180 RARITAN CENTER PARKWAY SUITE 101
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1150
Mailing Address - Country:US
Mailing Address - Phone:732-865-6481
Mailing Address - Fax:
Practice Address - Street 1:180 RARITAN CENTER PARKWAY SUITE 101
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1150
Practice Address - Country:US
Practice Address - Phone:732-865-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2022-10-24
Deactivation Date:2021-09-10
Deactivation Code:
Reactivation Date:2022-10-24
Provider Licenses
StateLicense IDTaxonomies
NJ26NPO6337800164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse