Provider Demographics
NPI:1871226738
Name:DOMINIQUE, OPHILLIA (FNP)
Entity type:Individual
Prefix:
First Name:OPHILLIA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 THORNBLADE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-8048
Mailing Address - Country:US
Mailing Address - Phone:856-912-4867
Mailing Address - Fax:
Practice Address - Street 1:501 RADFORD BLVD
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-5001
Practice Address - Country:US
Practice Address - Phone:803-605-0270
Practice Address - Fax:843-605-0268
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26107363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily