Provider Demographics
NPI:1619651635
Name:PIQUE, DWANA F (RPT)
Entity Type:Individual
Prefix:
First Name:DWANA
Middle Name:F
Last Name:PIQUE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 ADDISON PL
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9486
Mailing Address - Country:US
Mailing Address - Phone:912-210-7102
Mailing Address - Fax:
Practice Address - Street 1:7302 ADDISON PL
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9486
Practice Address - Country:US
Practice Address - Phone:912-210-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2829157246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy