=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104405216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ANN DOMINIQUE-BRANLEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2021
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 N ACADIA RD STE 100
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-4897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-447-9045
-----------------------------------------------------
Fax | 985-447-3349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 WELCH RD
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94304-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-497-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 340450
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------