Provider Demographics
NPI:1700424025
Name:COLEY, DOMINIQUE SADE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SADE
Last Name:COLEY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 KNIGHT ARNOLD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-2128
Mailing Address - Country:US
Mailing Address - Phone:901-572-1573
Mailing Address - Fax:
Practice Address - Street 1:4041 KNIGHT ARNOLD RD STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-2128
Practice Address - Country:US
Practice Address - Phone:901-572-1573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA209864363LP0808X
TN26786363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health