Provider Demographics
NPI:1124103965
Name:PINILLA, DOMINIQUE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:PINILLA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 JOY SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-0288
Mailing Address - Country:US
Mailing Address - Phone:423-943-0856
Mailing Address - Fax:
Practice Address - Street 1:3720 DAVINCI CT STE 400
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7625
Practice Address - Country:US
Practice Address - Phone:706-582-4462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704375947363L00000X
TX1016285363L00000X
LA215869363L00000X
FLAPRN9450731363L00000X
NC5013683363L00000X
MS810603363L00000X
IAA173673363L00000X
SC2833363L00000X
KY4005394363L00000X
WV117974363L00000X
AL3-000363363LF0000X
PASP022300363L00000X
AZAP5358363L00000X
GARN253292363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ68196Medicare UPIN