Provider Demographics
NPI:1770351819
Name:MEREDITH, DOMINIQUE DION (CNA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DION
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:DION
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14514 GRANDVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2231
Mailing Address - Country:US
Mailing Address - Phone:313-220-5720
Mailing Address - Fax:
Practice Address - Street 1:14514 GRANDVILLE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2231
Practice Address - Country:US
Practice Address - Phone:313-220-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230010704720405376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide