Provider Demographics
NPI:1407196918
Name:DOMAN, JESSICA RAE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:DOMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 WOLVERINE TRL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 WOLVERINE TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5656
Practice Address - Country:US
Practice Address - Phone:615-459-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000161022163W00000X
TNAPN0000017365363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse