MEDICARE: DOMINIQUE SMITH

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	164W00000X	Licensed Practical Nurse	4703111582	MI

General Provider Information

NPI Number	:	1689067043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE SMITH

Provider Business Mailing Address
First Line	:	18424 KLINGER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1718
Country	:	US
Telephone Number	:	313-618-3342
Fax Number	:

Provider Business Practice Location Address
First Line	:	18424 KLINGER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1718
Country	:	US
Telephone Number	:	313-618-3342
Fax Number	:

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

Provider Enumeration Date	:	03/10/2015
Last Update Date	:	03/10/2015

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Directions to “ DOMINIQUE SMITH ” Practice Location

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