Provider Demographics
NPI:1154787505
Name:RYAN, DOMONIQUE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PACKARD CT APT C
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14301-2802
Mailing Address - Country:US
Mailing Address - Phone:716-579-0228
Mailing Address - Fax:
Practice Address - Street 1:3 PACKARD CT APT C
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-2802
Practice Address - Country:US
Practice Address - Phone:716-579-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health