1104405216 NPI number — NICOLE ANN DOMINIQUE-BRANLEY MD

Table of content: NICOLE ANN DOMINIQUE-BRANLEY MD (NPI 1104405216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104405216 NPI number — NICOLE ANN DOMINIQUE-BRANLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINIQUE-BRANLEY
Provider First Name:
NICOLE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOMINIQUE
Provider Other First Name:
NICOLE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104405216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 WELCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94304-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-497-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 N ACADIA RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THIBODAUX
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70301-4897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-447-9045
Provider Business Practice Location Address Fax Number:
985-447-3349
Provider Enumeration Date:
04/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  340450 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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