Provider Demographics
NPI:1255052759
Name:SPILLMAN, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SPILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:SPILLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4821 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3955
Mailing Address - Country:US
Mailing Address - Phone:312-508-2824
Mailing Address - Fax:
Practice Address - Street 1:4821 W 103RD ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3955
Practice Address - Country:US
Practice Address - Phone:312-508-2824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical