Provider Demographics
NPI:1568249951
Name:COUTURE, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:COUTURE
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 1:620 RENSHAW ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2656
Mailing Address - Country:US
Mailing Address - Phone:248-710-7173
Mailing Address - Fax:
Practice Address - Street 1:2111 WOODWARD AVE STE 920
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-3421
Practice Address - Country:US
Practice Address - Phone:313-488-4332
Practice Address - Fax:313-488-4332
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704401139363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner