Provider Demographics
NPI:1336675529
Name:EDWARDS, DOMENIQUE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:DOMENIQUE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 SW NEVADA ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-2535
Mailing Address - Country:US
Mailing Address - Phone:206-920-5949
Mailing Address - Fax:
Practice Address - Street 1:5602 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1515
Practice Address - Country:US
Practice Address - Phone:206-538-2255
Practice Address - Fax:206-538-2266
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60786069163W00000X
WAAP60793275363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821751702OtherTYPE 2 NPI