Provider Demographics
NPI:1760907968
Name:DOMINIC, KENYA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:DOMINIC
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VOLUMINOUS VIRGIN HAIR
Mailing Address - Street 2:445 E G MILES PARKWAY STE 207
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3246
Mailing Address - Country:US
Mailing Address - Phone:912-877-7797
Mailing Address - Fax:912-877-7797
Practice Address - Street 1:445 E.G. MILES PARKWAY STE 207
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-877-7797
Practice Address - Fax:912-877-7797
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management