Provider Demographics
NPI:1992374433
Name:TROTTER, DOMONIQUE DESIREE' (CNM)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:DESIREE'
Last Name:TROTTER
Suffix:
Gender:
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MOYE BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BOULEVARD
Practice Address - Street 2:EAST CAROLINA UNIVERSITY COLLEGE OF NURSING
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-744-6478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-20
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185930367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992374433Medicaid