Provider Demographics
NPI:1821751702
Name:DOMENIQUE EDWARDS, PLLC
Entity Type:Organization
Organization Name:DOMENIQUE EDWARDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMENIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:206-538-2255
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336675529OtherTYPE I NPI