Provider Demographics
NPI:1619651247
Name:THOMPSON, DOMANIQUE
Entity Type:Individual
Prefix:
First Name:DOMANIQUE
Middle Name:
Last Name:THOMPSON
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 1:1610 PRESTON AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-3518
Mailing Address - Country:US
Mailing Address - Phone:330-809-8767
Mailing Address - Fax:
Practice Address - Street 1:1610 PRESTON AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-3518
Practice Address - Country:US
Practice Address - Phone:330-809-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health