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NPI Code Detail

MEDICARE: DOMINIQUE SHANICIA GRISBY PMHNP

MEDICARE: DOMINIQUE SHANICIA GRISBY PMHNP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner237531LA

General Provider Information

NPI Number : 1417781030
Entity Type Code : Individual
Provider Name (Legal Business Name) : DOMINIQUE SHANICIA GRISBY PMHNP
Provider Business Mailing Address
First Line : 201 RUE BEAUREGARD STE 202
Second Line :
City : LAFAYETTE
State : LA
Zip : 70508-3251
Country : US
Telephone Number : 713-850-0049
Fax Number :
Provider Business Practice Location Address
First Line : 622 RIVERSIDE DR
Second Line :
City : MONROE
State : LA
Zip : 71201-6211
Country : US
Telephone Number : 318-398-0945
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/27/2024
Last Update Date : 04/28/2026

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