Provider Demographics
NPI:1104294263
Name:DIDOMINICIS, CHANTEL
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:DIDOMINICIS
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 1:2289 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1115
Mailing Address - Country:US
Mailing Address - Phone:810-813-0057
Mailing Address - Fax:
Practice Address - Street 1:2289 MELODY LN
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1115
Practice Address - Country:US
Practice Address - Phone:810-813-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide