Provider Demographics
NPI:1699219840
Name:WEISS, DOMINIQUE ELIZABETH (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:ELIZABETH
Last Name:WEISS
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 E 31ST ST
Mailing Address - Street 2:APT 15A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6800
Mailing Address - Country:US
Mailing Address - Phone:305-924-0113
Mailing Address - Fax:
Practice Address - Street 1:155 E 31ST ST
Practice Address - Street 2:APT 15A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6800
Practice Address - Country:US
Practice Address - Phone:305-924-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608607163W00000X
NY62093163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse