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General NPI Number Information
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NPI Number | 1922770429
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Entity Type | Individual
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Provider Name | DOMINIQUE DEVON NELSON
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Gender | Female
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Dates
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Enumeration Date | 10/02/2021
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Last Update Date | 10/02/2021
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Provider Practice Location Address
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Address Line | 13259 S CENTRAL AVE
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City | CRESTWOOD
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State | IL
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Zip | 60418-2901
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Country | US
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Telephone | 708-597-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 3728 215TH ST
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City | MATTESON
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State | IL
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Zip | 60443-2754
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Country | US
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Telephone | 708-774-7041
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 057.005651
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License Number State | IL
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