Provider Demographics
NPI:1154957199
Name:ARTHUR, DOMINIQUE LEESHAN
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LEESHAN
Last Name:ARTHUR
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 1:2419 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-5727
Mailing Address - Country:US
Mailing Address - Phone:321-349-0004
Mailing Address - Fax:
Practice Address - Street 1:2419 AUBURN DR
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5727
Practice Address - Country:US
Practice Address - Phone:321-349-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver