Provider Demographics
NPI:1043855729
Name:DOMINIQUE, JOHANNE RICHARD (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JOHANNE
Middle Name:RICHARD
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SW 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3685
Mailing Address - Country:US
Mailing Address - Phone:786-210-3515
Mailing Address - Fax:
Practice Address - Street 1:7900 NW 27TH AVE STE 50
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-4909
Practice Address - Country:US
Practice Address - Phone:305-758-0591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005018363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105483200Medicaid