Healthcare Provider Details

I. General information

NPI: 1407381973
Provider Name (Legal Business Name): MISS DOMINIQUE STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 RASBERRY LANE APT.1901
SHREVEPORT LA
71129
US

IV. Provider business mailing address

6800 RASBERRY LN APT 1901
SHREVEPORT LA
71129-2525
US

V. Phone/Fax

Practice location:
  • Phone: 318-834-5287
  • Fax:
Mailing address:
  • Phone: 318-834-5287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: