Provider Demographics
NPI:1700267895
Name:ANDERSON, DOMONIQUE DANIELLE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:DANIELLE
Last Name:ANDERSON
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 1:140 E POINTE LN APT C09
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1978
Mailing Address - Country:US
Mailing Address - Phone:810-875-3584
Mailing Address - Fax:
Practice Address - Street 1:140 E POINTE LN APT C09
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1978
Practice Address - Country:US
Practice Address - Phone:810-875-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other