Provider Demographics
NPI:1730848524
Name:MURPHY, DOMINIQUE TIARA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:TIARA
Last Name:MURPHY
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 1:614 W WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-4757
Mailing Address - Country:US
Mailing Address - Phone:850-291-0198
Mailing Address - Fax:
Practice Address - Street 1:614 W WRIGHT ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-4757
Practice Address - Country:US
Practice Address - Phone:850-356-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238019372600000X, 376J00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM610178948870Medicaid