Provider Demographics
NPI:1538799325
Name:JAMES, DOMINIQUE B
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:B
Last Name:JAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WILERS GRV
Mailing Address - Street 2:
Mailing Address - City:RITTMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44270-1823
Mailing Address - Country:US
Mailing Address - Phone:419-207-2429
Mailing Address - Fax:
Practice Address - Street 1:546 N UNION ST
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-1040
Practice Address - Country:US
Practice Address - Phone:419-207-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.023773Medicaid