Healthcare Provider Details

I. General information

NPI: 1063823045
Provider Name (Legal Business Name): DOMINIQUE MICHELLE VONADOR DOM, LAC, AP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 59TH ST W
BRADENTON FL
34209-7017
US

IV. Provider business mailing address

2215 59TH ST W
BRADENTON FL
34209-7017
US

V. Phone/Fax

Practice location:
  • Phone: 941-761-4994
  • Fax:
Mailing address:
  • Phone: 941-761-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP3455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: