Provider Demographics
NPI:1194579987
Name:WAKEFIELD, DOMINIQUE LINVAL (STNA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LINVAL
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:LINVAL
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STNA
Mailing Address - Street 1:27230 CARLYSLE ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2556
Mailing Address - Country:US
Mailing Address - Phone:248-229-2673
Mailing Address - Fax:313-528-8167
Practice Address - Street 1:5822 TETHERWOOD DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-1614
Practice Address - Country:US
Practice Address - Phone:248-229-2673
Practice Address - Fax:313-528-8167
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH322280290117376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide