Basic Information
| Provider Information | |||||||||
| NPI: | 1780318014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUILLAUME | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | GISELE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSN, AGPCNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 N STREEPER ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212241250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705617965 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 N WOLFE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212052110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103288667 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2022 | ||||||||
| LastUpdateDate: | 08/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN256248 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.