Provider Demographics
NPI:1669706933
Name:SHIELDS, DOMINIQUE D
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:D
Last Name:SHIELDS
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 1:1526 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5518
Mailing Address - Country:US
Mailing Address - Phone:215-463-2000
Mailing Address - Fax:215-463-2200
Practice Address - Street 1:1526 S FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-5518
Practice Address - Country:US
Practice Address - Phone:215-463-2000
Practice Address - Fax:215-463-2200
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-19
Last Update Date:2009-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy