Provider Demographics
NPI:1194479683
Name:KOOMSON, DOMONIQUE BATTLE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:BATTLE
Last Name:KOOMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOMONIQUE
Other - Middle Name:DESHA
Other - Last Name:BATTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3637 CAPE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3637 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4457
Practice Address - Country:US
Practice Address - Phone:910-491-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant