Provider Demographics
NPI:1588336606
Name:DOMINIQUE, KINDRA (CRNA)
Entity type:Individual
Prefix:
First Name:KINDRA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MYRTLE ST APT 418
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5449
Mailing Address - Country:US
Mailing Address - Phone:772-708-1493
Mailing Address - Fax:
Practice Address - Street 1:671 WINYAH DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1226
Practice Address - Country:US
Practice Address - Phone:407-303-8016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027128367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered