Provider Demographics
NPI:1811406507
Name:PALUMBO, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:PALUMBO
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 1:1536 SE 15TH CT APT 602
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-7309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:880 NW 13TH ST STE 2B
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2342
Practice Address - Country:US
Practice Address - Phone:561-361-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant