Provider Demographics
NPI:1104405216
Name:DOMINIQUE-BRANLEY, NICOLE ANN (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:DOMINIQUE-BRANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:DOMINIQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:725 WELCH RD
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1601
Mailing Address - Country:US
Mailing Address - Phone:650-497-8000
Mailing Address - Fax:
Practice Address - Street 1:604 N ACADIA RD STE 100
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-447-9045
Practice Address - Fax:985-447-3349
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA340450208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics