Provider Demographics
NPI:1639720725
Name:BOONE, DOMONIQUE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:BOONE
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 1:1460 E 108TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1221
Mailing Address - Country:US
Mailing Address - Phone:216-235-3217
Mailing Address - Fax:
Practice Address - Street 1:1460 E 108TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1221
Practice Address - Country:US
Practice Address - Phone:216-235-3217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide