Provider Demographics
NPI:1861761348
Name:COCHRAN, DOMONIQUE NIKKI (FNP)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:NIKKI
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DOMONIQUE
Other - Middle Name:HAVARD
Other - Last Name:COCHRAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:MS
Mailing Address - Zip Code:39555-0850
Mailing Address - Country:US
Mailing Address - Phone:228-588-2938
Mailing Address - Fax:228-588-9399
Practice Address - Street 1:7001 HWY 614
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:MS
Practice Address - Zip Code:39555
Practice Address - Country:US
Practice Address - Phone:228-588-2938
Practice Address - Fax:228-588-9399
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09336715Medicaid
MS09336715Medicaid