Provider Demographics
NPI:1881131308
Name:MATTHEWS, DOMONIQUE (FNP-C, CRNP)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:FNP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W. NORTH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217
Mailing Address - Country:US
Mailing Address - Phone:410-396-0186
Mailing Address - Fax:410-545-1540
Practice Address - Street 1:1515 W. NORTH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217
Practice Address - Country:US
Practice Address - Phone:410-396-0186
Practice Address - Fax:410-545-1540
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193190163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse