Provider Demographics
NPI:1144030180
Name:JOHNSON, DOMONIQUE MICHELLE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:MICHELLE
Last Name:JOHNSON
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 1:421 IDORA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-3111
Mailing Address - Country:US
Mailing Address - Phone:234-529-7986
Mailing Address - Fax:
Practice Address - Street 1:421 IDORA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-3111
Practice Address - Country:US
Practice Address - Phone:234-529-7986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant