Provider Demographics
NPI:1710541610
Name:MARTIN, DOMINIQUE ANTOINETTE (RN)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ANTOINETTE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-5329
Mailing Address - Country:US
Mailing Address - Phone:424-230-9000
Mailing Address - Fax:424-389-7097
Practice Address - Street 1:1542 W 125TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5329
Practice Address - Country:US
Practice Address - Phone:424-230-9000
Practice Address - Fax:424-389-7097
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA779452163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management