Provider Demographics
NPI:1184395287
Name:MITCHELL, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:MITCHELL
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 1:4731 W LEON TER
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2332
Mailing Address - Country:US
Mailing Address - Phone:414-241-0945
Mailing Address - Fax:
Practice Address - Street 1:4731 W LEON TER
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2332
Practice Address - Country:US
Practice Address - Phone:414-241-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date: