Basic Information
Provider Information | |||||||||
NPI: | 1053735696 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DENNIS | ||||||||
FirstName: | DOMINIQUE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 131 SAUNDERSVILLE RD | ||||||||
Address2: | 160 | ||||||||
City: | HENDERSONVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370758903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158243737 | ||||||||
FaxNumber: | 8555404722 | ||||||||
Practice Location | |||||||||
Address1: | 3443 DICKERSON PIKE | ||||||||
Address2: | SUITE 250 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372072519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158243737 | ||||||||
FaxNumber: | 8555404722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2014 | ||||||||
LastUpdateDate: | 08/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 17624 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 7100296020 | 05 | KY |   | MEDICAID | Q007179 | 05 | TN |   | MEDICAID | 6021198 | 01 | TN | BCBS OF TN | OTHER |