Healthcare Provider Details

I. General information

NPI: 1336675529
Provider Name (Legal Business Name): DOMENIQUE EDWARDS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2017
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 CALIFORNIA AVE SW
SEATTLE WA
98136-1515
US

IV. Provider business mailing address

2611 SW NEVADA ST UNIT B
SEATTLE WA
98126-2535
US

V. Phone/Fax

Practice location:
  • Phone: 206-538-2255
  • Fax: 206-538-2266
Mailing address:
  • Phone: 206-920-5949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60786069
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60793275
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: