Healthcare Provider Details

I. General information

NPI: 1134665136
Provider Name (Legal Business Name): DOMINIQUE THOMAS RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE ATTN: MCHJ-CLQ-C
TACOMA WA
98431-1100
US

IV. Provider business mailing address

2604 MARIETTA ST
STEILACOOM WA
98388-2852
US

V. Phone/Fax

Practice location:
  • Phone: 253-226-5622
  • Fax:
Mailing address:
  • Phone: 931-338-3631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number154729
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: