Healthcare Provider Details

I. General information

NPI: 1104373620
Provider Name (Legal Business Name): DOMINIQUE DEAR CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 N. HUDSON ST. APT.594
CHICAGO IL
60610-5828
US

IV. Provider business mailing address

1365 N. HUDSON ST. APT.594
CHICAGO IL
60610-5828
US

V. Phone/Fax

Practice location:
  • Phone: 312-513-6525
  • Fax:
Mailing address:
  • Phone: 312-513-6525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number0564-1436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: