Healthcare Provider Details

I. General information

NPI: 1588596076
Provider Name (Legal Business Name): DOMINIQUE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 ALPHA DR STE G
HIGHLAND HEIGHTS OH
44143-2139
US

IV. Provider business mailing address

4418 BROOKS RD
CLEVELAND OH
44105-6087
US

V. Phone/Fax

Practice location:
  • Phone: 440-664-1446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN.CNP.0041279
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: