Provider Demographics
NPI:1760217608
Name:WALTON, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:WALTON
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 1:10752 NEWGATE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46231-1817
Mailing Address - Country:US
Mailing Address - Phone:317-491-4778
Mailing Address - Fax:
Practice Address - Street 1:10752 NEWGATE LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46231-1817
Practice Address - Country:US
Practice Address - Phone:317-491-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant