Provider Demographics
NPI:1720663701
Name:LOUIS, DOMONIQUE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:LOUIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 CAMINO DIABLO STE 105
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3945
Mailing Address - Country:US
Mailing Address - Phone:800-892-2695
Mailing Address - Fax:
Practice Address - Street 1:8295 TOURNAMENT DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8906
Practice Address - Country:US
Practice Address - Phone:800-892-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104470363LP0808X
TN29321363LP0808X
IAG166642363LP0808X
NM64857363LP0808X
CA95019437363LP0808X
WAAP61249213363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health