Healthcare Provider Details

I. General information

NPI: 1497682520
Provider Name (Legal Business Name): DOMINIQUE S BLUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 ELLINWOOD DR
IRONDEQUOIT NY
14622-2334
US

IV. Provider business mailing address

194 ELLINWOOD DR
IRONDEQUOIT NY
14622-2334
US

V. Phone/Fax

Practice location:
  • Phone: 585-775-6068
  • Fax:
Mailing address:
  • Phone: 585-775-6068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number342461-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: