Provider Demographics
NPI:1891258521
Name:BURKE, DOMINIQUE
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:BURKE
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 1:35 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5344
Mailing Address - Country:US
Mailing Address - Phone:301-739-3333
Mailing Address - Fax:301-739-3337
Practice Address - Street 1:35 MADISON AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5344
Practice Address - Country:US
Practice Address - Phone:301-739-3333
Practice Address - Fax:301-739-3337
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4390251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health