Provider Demographics
NPI:1700672243
Name:THURSTON, DOMINIQUE ALYSSA (DO)
Entity type:Individual
Prefix:MISS
First Name:DOMINIQUE
Middle Name:ALYSSA
Last Name:THURSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DURHAMOC LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3007
Mailing Address - Country:US
Mailing Address - Phone:631-575-6089
Mailing Address - Fax:
Practice Address - Street 1:3415 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2403
Practice Address - Country:US
Practice Address - Phone:718-741-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program