Provider Demographics
NPI:1205302395
Name:HARDMAN, DOMONIQUE L (PTA)
Entity type:Individual
Prefix:MR
First Name:DOMONIQUE
Middle Name:L
Last Name:HARDMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2076 SW FALLON LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1314
Mailing Address - Country:US
Mailing Address - Phone:386-344-9095
Mailing Address - Fax:
Practice Address - Street 1:2076 SW FALLON LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1314
Practice Address - Country:US
Practice Address - Phone:386-344-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28905225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant