Provider Demographics
NPI:1497248520
Name:HOWARD, DOMINIQUE NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:HOWARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:NICOLE
Other - Last Name:FORTUNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3070 WINDWARD PLZ STE F411
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-8771
Mailing Address - Country:US
Mailing Address - Phone:678-713-7516
Mailing Address - Fax:
Practice Address - Street 1:3070 WINDWARD PLZ STE F411
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-8771
Practice Address - Country:US
Practice Address - Phone:678-713-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN299261363LF0000X
LAAP09895363LF0000X
GARN299261207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine