MEDICARE: DOMINIQUE PELOTE APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	26NJ14854900	NJ

General Provider Information

NPI Number	:	1154009678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE PELOTE APN

Provider Business Mailing Address
First Line	:	286 HAWTHORNE ST
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-2013
Country	:	US
Telephone Number	:	917-204-2763
Fax Number	:

Provider Business Practice Location Address
First Line	:	286 HAWTHORNE ST
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-2013
Country	:	US
Telephone Number	:	917-204-2763
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	07/05/2023

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