Provider Demographics
NPI:1093519886
Name:CLARK, DOMINQUE
Entity type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WICKHAM FARM DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2948
Mailing Address - Country:US
Mailing Address - Phone:214-264-0962
Mailing Address - Fax:
Practice Address - Street 1:117 WICKHAM FARM DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2948
Practice Address - Country:US
Practice Address - Phone:214-264-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care