Provider Demographics
NPI:1336907617
Name:DOMINO, FALLON
Entity Type:Individual
Prefix:MS
First Name:FALLON
Middle Name:
Last Name:DOMINO
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 1:6824 LAKE WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70126-2121
Mailing Address - Country:US
Mailing Address - Phone:248-808-4118
Mailing Address - Fax:
Practice Address - Street 1:6824 LAKE WILLOW DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70126-2121
Practice Address - Country:US
Practice Address - Phone:248-808-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator