Provider Demographics
NPI:1063062651
Name:PAUL-THOMPSON, DOMINIQUE S
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:S
Last Name:PAUL-THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:S
Other - Last Name:PAUL-THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:112 DEERCREEK PARKWAY
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224
Mailing Address - Country:US
Mailing Address - Phone:470-771-2007
Mailing Address - Fax:
Practice Address - Street 1:112 DEERCREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:470-771-2007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X, 251E00000X
GA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA