Provider Demographics
NPI:1982360087
Name:LITTLE, DOMONIQUE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:LITTLE
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 1:1251 PRAIRIE PRAIRIE LN
Mailing Address - Street 2:14306
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:321-289-1097
Mailing Address - Fax:
Practice Address - Street 1:1251 PRAIRIE PRAIRIE LN
Practice Address - Street 2:14306
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:321-289-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker