Individual ProviderDominque Latreace WathanCase Manager/Care CoordinatorOther Service ProvidersPractice Address111 W. 1st St, Shawnee, OK 74804-2202(405) 273-1170PECOS EnrollmentBased on the most recent information from CMS, provider Dominque Latreace Wathan does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1992349427Provider TypeIndividualFull NameWathan, Dominque LatreaceCredentialCMII, BHWCGenderFemaleSole ProprietorNoEnumeration Date10/28/2019Last Updated3/4/2025Contact InformationPractice LocationPractice Address111 W. 1st St, Shawnee, OK 74804-2202Phone(405) 273-1170Fax(405) 241-6447Mailing LocationMailing Address111 W 1st St, Chandler, OK 74834-2004Phone(405) 273-1170Fax(405) 241-6447Provider TaxonomiesCodeDescriptionLicenseCode171M00000XPrimaryDescriptionCase Manager/Care CoordinatorOther Service ProvidersLicenseUnlisted IssuerCode175T00000XDescriptionPeer SpecialistOther Service ProvidersLicenseUnlisted Issuer