Healthcare Provider Details

I. General information

NPI: 1417781030
Provider Name (Legal Business Name): DOMINIQUE SHANICIA GRISBY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 RIVERSIDE DR
MONROE LA
71201-6211
US

IV. Provider business mailing address

201 RUE BEAUREGARD STE 202
LAFAYETTE LA
70508-3251
US

V. Phone/Fax

Practice location:
  • Phone: 318-398-0945
  • Fax:
Mailing address:
  • Phone: 713-850-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number237531
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: