NPIMap

Individual provider Active NPI

Kimberly Irby Dominique, FNP

  • Family Nurse Practitioner
  • Pascagoula, MS
National Provider Identifier
1902496524
Registry record updated Jan 19, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
904287 Issued in MS
Practice address
4310 Chicot St
Pascagoula, MS 39581-4700
Phone
(228) 205-4737
Fax
(228) 205-4964
NPI assigned
Jan 19, 2021
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 904287 MS Primary

Addresses

Primary practice location

4310 Chicot St
Pascagoula, MS 39581-4700

Mailing address

3709 Oak Ave
Gulfport, MS 39507-3108
Phone (228) 596-5301

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210916001822 MS Practitioner - Nurse Practitioner 9638576788 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Memorial Hospital at GulfportGroup PAC ID 2466524012, 473 clinicians

Practice addresses (Care Compare)

4500 13TH St
Gulfport, MS 39501-2515
Phone (228) 867-5201

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
904287MSMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Gulf Coast Wound Associates LLC CurrentSince May 1, 2023 Accepting new patients
Memorial Hospital at Gulfport Current Accepting new patients
Forever Young Mens Health Clinic PLLC CurrentSince Jun 8, 2024 Accepting new patients
Memorial Hospital at Gulfport CurrentSince Aug 16, 2021 Accepting new patients
Memorial Hospital at Gulfport CurrentSince Aug 16, 2021 Accepting new patients
Action Potential, PLLC PastSince Jun 8, 2024 Accepting new patients

Locations

2093 E Pass Rd
Ste B
Gulfport, MS 39507

8837 Lorraine Rd
Ste A
Gulfport, MS 39503
Phone (228) 241-1000

1340 Broad Ave
Ste 440
Gulfport, MS 39501
Phone (228) 867-4856

4500 13th St
Gulfport, MS 39501
Phone (228) 236-3872

1436 Central Ave E
Wiggins, MS 39577
Phone (601) 928-1889

Interoperability endpoints

  • Direct secure messaging: kdominique@direct.mhg.com

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 60

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 60

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1611014400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1611014400000",
    "number": "1902496524",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3709 OAK AVE",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395073108",
            "telephone_number": "228-596-5301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4310 CHICOT ST",
            "city": "PASCAGOULA",
            "state": "MS",
            "postal_code": "395814700",
            "telephone_number": "228-205-4737",
            "fax_number": "228-205-4964"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOMINIQUE",
        "first_name": "KIMBERLY",
        "middle_name": "IRBY",
        "name_prefix": "Mrs.",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-01-19",
        "last_updated": "2021-01-19",
        "certification_date": "2021-01-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "904287",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pascagoula, MS

Sources for this page

Verify at the official NPI Registry.