Provider Demographics
NPI:1619545191
Name:BURGESS, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BURGESS
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 1:203 JOE GIBSON DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27249-9811
Mailing Address - Country:US
Mailing Address - Phone:919-508-4483
Mailing Address - Fax:
Practice Address - Street 1:203 JOE GIBSON DR
Practice Address - Street 2:
Practice Address - City:GIBSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27249-9811
Practice Address - Country:US
Practice Address - Phone:919-508-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula