Healthcare Provider Details

I. General information

NPI: 1386883718
Provider Name (Legal Business Name): ANGEL DOMINIQUE GRESHAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. ANGEL DOMINIQUE BLAIR

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 GEORGE WASHINGTON HWY N STE 2
CHESAPEAKE VA
23323-1852
US

IV. Provider business mailing address

2872 E POINT DR
CHESAPEAKE VA
23321-4125
US

V. Phone/Fax

Practice location:
  • Phone: 757-773-6130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024188654
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: