Provider Demographics
NPI:1306610282
Name:RODRIGUEZ, DOMINIQUE NIKOL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NIKOL
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1205
Mailing Address - Country:US
Mailing Address - Phone:716-831-2700
Mailing Address - Fax:
Practice Address - Street 1:3345 SOUTHWESTERN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1506
Practice Address - Country:US
Practice Address - Phone:716-662-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404424363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health