MEDICARE: MISS DOMINIQUE CRYSTAL HALLANY HHA

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	251E00000X	Home Health Agency	10575	DC

General Provider Information

NPI Number	:	1992114078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DOMINIQUE CRYSTAL HALLANY HHA

Provider Business Mailing Address
First Line	:	3425 TOLEDO TER
Second Line	:	APT. H3
City	:	HYATTSVILLE
State	:	MD
Zip	:	20782-1961
Country	:	US
Telephone Number	:	240-855-3750
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 TOLEDO TER
Second Line	:	APT. H3
City	:	HYATTSVILLE
State	:	MD
Zip	:	20782-1961
Country	:	US
Telephone Number	:	240-855-3750
Fax Number	:

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

Provider Enumeration Date	:	08/04/2014
Last Update Date	:	08/04/2014

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