Provider Demographics
NPI:1699493973
Name:ANTOINE, DOMINIQUE DUJUAN (NP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DUJUAN
Last Name:ANTOINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3747
Mailing Address - Country:US
Mailing Address - Phone:617-306-6181
Mailing Address - Fax:
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily