Healthcare Provider Details

I. General information

NPI: 1043752009
Provider Name (Legal Business Name): DOMECIA NEWMON APRN,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6084 APPLE TREE DR STE 11
MEMPHIS TN
38115-0305
US

IV. Provider business mailing address

6084 APPLE TREE DR STE 11
MEMPHIS TN
38115-0305
US

V. Phone/Fax

Practice location:
  • Phone: 901-779-6500
  • Fax: 901-779-6555
Mailing address:
  • Phone: 901-779-6500
  • Fax: 901-779-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901785
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21632
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number21632
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: