Provider Demographics
NPI:1720746506
Name:ANDERSON, DOMINIQUE L
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:L
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 1:613 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1454
Mailing Address - Country:US
Mailing Address - Phone:234-716-6952
Mailing Address - Fax:
Practice Address - Street 1:613 OXFORD ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1454
Practice Address - Country:US
Practice Address - Phone:234-716-6952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty