Provider Demographics
NPI:1417781030
Name:GRISBY, DOMINIQUE SHANICIA (PMHNP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SHANICIA
Last Name:GRISBY
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 RUE BEAUREGARD STE 202
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3251
Mailing Address - Country:US
Mailing Address - Phone:713-850-0049
Mailing Address - Fax:
Practice Address - Street 1:201 RUE BEAUREGARD STE 202
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3251
Practice Address - Country:US
Practice Address - Phone:713-850-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA237531363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health