Healthcare Provider Details

I. General information

NPI: 1396667465
Provider Name (Legal Business Name): DOMINIQUE DAY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GULF BREEZE PKWY
GULF BREEZE FL
32561-7809
US

IV. Provider business mailing address

1040 GULF BREEZE PKWY
GULF BREEZE FL
32561-7809
US

V. Phone/Fax

Practice location:
  • Phone: 448-227-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL7725
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: