Provider Demographics
NPI:1255871174
Name:BONNEGUE EGALITE, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BONNEGUE EGALITE
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 1:961 SIESTA DR
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33415-1312
Mailing Address - Country:US
Mailing Address - Phone:561-839-0478
Mailing Address - Fax:561-337-9025
Practice Address - Street 1:961 SIESTA DR
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:FL
Practice Address - Zip Code:33415-1312
Practice Address - Country:US
Practice Address - Phone:561-839-0478
Practice Address - Fax:561-337-9025
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist