Basic Information
| Provider Information | |||||||||
| NPI: | 1861761348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COCHRAN | ||||||||
| FirstName: | DOMONIQUE | ||||||||
| MiddleName: | NIKKI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COCHRAN | ||||||||
| OtherFirstName: | DOMONIQUE | ||||||||
| OtherMiddleName: | HAVARD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 850 | ||||||||
| Address2: | |||||||||
| City: | HURLEY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395550850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285882938 | ||||||||
| FaxNumber: | 2285889399 | ||||||||
| Practice Location | |||||||||
| Address1: | 7001 HWY 614 | ||||||||
| Address2: | |||||||||
| City: | HURLEY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285882938 | ||||||||
| FaxNumber: | 2285889399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R854690 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 09336715 | 05 | MS | MEDICAID |