Provider Demographics
NPI:1902496524
Name:DOMINIQUE, KIMBERLY IRBY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:IRBY
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 1:3709 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3108
Mailing Address - Country:US
Mailing Address - Phone:228-596-5301
Mailing Address - Fax:
Practice Address - Street 1:4310 CHICOT ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4700
Practice Address - Country:US
Practice Address - Phone:228-205-4737
Practice Address - Fax:228-205-4964
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904287363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily