Healthcare Provider Details

I. General information

NPI: 1992556724
Provider Name (Legal Business Name): DOMINIQUE LIDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE SZYMKIEWICZ

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 03/29/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SENECA ST MAIL STOP: H8-GME
SEATTLE WA
98101
US

IV. Provider business mailing address

2000 SW 16TH ST APT 27
GAINESVILLE FL
32608-1437
US

V. Phone/Fax

Practice location:
  • Phone: 206-583-6079
  • Fax:
Mailing address:
  • Phone: 305-318-1964
  • 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: