Provider Demographics
NPI:1649983990
Name:PHELPS, DOMINIQUE (CNM)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4271
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:855-495-5457
Practice Address - Street 1:1650 HASLETT RD
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-7615
Practice Address - Country:US
Practice Address - Phone:517-853-5576
Practice Address - Fax:517-853-5577
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326306163W00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse