Healthcare Provider Details

I. General information

NPI: 1063294205
Provider Name (Legal Business Name): DOMINIQUE MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 12/17/2025
Certification Date: 08/29/2023
Deactivation Date: 12/10/2025
Reactivation Date: 12/17/2025

III. Provider practice location address

14410 SOMMERVILLE CT STE 101
MIDLOTHIAN VA
23113-6813
US

IV. Provider business mailing address

PO BOX 2243
CHARLOTTESVILLE VA
22902-2243
US

V. Phone/Fax

Practice location:
  • Phone: 804-897-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024188517
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: