Healthcare Provider Details

I. General information

NPI: 1235053240
Provider Name (Legal Business Name): DOMINIQUE COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TIFFANY COLLINS

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E WARREN AVE SUITE B
BROOKHAVEN MS
39601
US

IV. Provider business mailing address

135 E WARREN AVE STE B
BROOKHAVEN MS
39601-4146
US

V. Phone/Fax

Practice location:
  • Phone: 769-231-6359
  • Fax:
Mailing address:
  • Phone: 769-231-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: