Provider Demographics
NPI:1477103414
Name:HARNAGE, DOMINIQUE S (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:S
Last Name:HARNAGE
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:S
Other - Last Name:WILTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX414457801Medicaid
TX1F6946OtherMEDICARE
TXP02531920OtherMEDICARE RAIL ROAD