Provider Demographics
NPI:1992289045
Name:ANDERSON, DOMINIQUE BOWMAN (DNP, FNP, PMHNP)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:BOWMAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DNP, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4373
Mailing Address - Country:US
Mailing Address - Phone:225-246-9790
Mailing Address - Fax:225-246-9100
Practice Address - Street 1:3401 NORTH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-381-2621
Practice Address - Fax:225-387-7829
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10001363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2485385Medicaid