Healthcare Provider Details

I. General information

NPI: 1235667205
Provider Name (Legal Business Name): DWAYNE DUNKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16314 RIVERS REACH BLVD
PARRISH FL
34219-2782
US

IV. Provider business mailing address

16314 RIVERS REACH BLVD
PARRISH FL
34219-2782
US

V. Phone/Fax

Practice location:
  • Phone: 423-444-5896
  • Fax:
Mailing address:
  • Phone: 423-444-5896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174887
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11006893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: