Provider Demographics
NPI:1245721968
Name:WILLIAMS, DOMINIQUE LILLIAN MCCRAY (LAT, ATC, EMT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LILLIAN MCCRAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LAT, ATC, EMT
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:LILLIAN
Other - Last Name:MCCRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 CAMPANA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-9492
Mailing Address - Country:US
Mailing Address - Phone:919-325-6065
Mailing Address - Fax:
Practice Address - Street 1:11221 GALLERIA AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8137
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:919-562-9425
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP092137146N00000X
NC20000316062255A2300X
NCLAT-38772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic