Provider Demographics
NPI:1780318014
Name:GUILLAUME, DOMINIQUE GISELE (MSN, AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:GISELE
Last Name:GUILLAUME
Suffix:
Gender:F
Credentials:MSN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 N STREEPER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1250
Mailing Address - Country:US
Mailing Address - Phone:770-561-7965
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD STE A406
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3139
Practice Address - Country:US
Practice Address - Phone:301-262-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215205363LA2200X
GARN256248363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health