Provider Demographics
NPI:1295359545
Name:TAMMINGA, DOMENIQUE (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:DOMENIQUE
Middle Name:
Last Name:TAMMINGA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6228
Mailing Address - Country:US
Mailing Address - Phone:616-834-1417
Mailing Address - Fax:
Practice Address - Street 1:1743 STATE ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-6228
Practice Address - Country:US
Practice Address - Phone:616-834-1417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308086363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner