Provider Demographics
NPI:1366211138
Name:SULTON, DOMINIQUE SHUNTA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SHUNTA
Last Name:SULTON
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 1:5600 KEELE ST APT 1808
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2047
Mailing Address - Country:US
Mailing Address - Phone:251-550-7748
Mailing Address - Fax:
Practice Address - Street 1:5600 KEELE ST APT 1808
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2047
Practice Address - Country:US
Practice Address - Phone:251-550-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS60561251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care