Healthcare Provider Details

I. General information

NPI: 1225775596
Provider Name (Legal Business Name): MS. DOMINIQUE NICOLE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 PREMIERE PKWY STE 500
DULUTH GA
30097-8912
US

IV. Provider business mailing address

1257 IMAGE XING
LAWRENCEVILLE GA
30045-2287
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 562-606-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: