Healthcare Provider Details

I. General information

NPI: 1649983990
Provider Name (Legal Business Name): DOMINIQUE PHELPS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 HASLETT RD
HASLETT MI
48840-7615
US

IV. Provider business mailing address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-853-5576
  • Fax: 517-853-5577
Mailing address:
  • Phone: 517-374-7600
  • Fax: 855-495-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704326306
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: