Provider Demographics
NPI:1346874716
Name:CLARK, DOMINIQUE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
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 1:1540 APPLING CARE LN STE 105
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4947
Mailing Address - Country:US
Mailing Address - Phone:901-444-3970
Mailing Address - Fax:
Practice Address - Street 1:1540 APPLING CARE LN
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-4957
Practice Address - Country:US
Practice Address - Phone:901-444-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN174756163WE0003X
TN27344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency