MEDICARE: DOMONIQUE CHRISTIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1649738386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMONIQUE CHRISTIAN

Provider Business Mailing Address
First Line	:	PO BOX 19375
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-1375
Country	:	US
Telephone Number	:	817-891-0285
Fax Number	:

Provider Business Practice Location Address
First Line	:	2213 CLEARVIEW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4503
Country	:	US
Telephone Number	:	817-891-0285
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	03/12/2019

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Directions to “ DOMONIQUE CHRISTIAN ” Practice Location

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