Healthcare Provider Details

I. General information

NPI: 1669387221
Provider Name (Legal Business Name): DOMINQUE LYNNEA JOHNSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MOUNT ZION RD
UNION CITY TN
38261-7694
US

IV. Provider business mailing address

1008 MOUNT ZION RD
UNION CITY TN
38261-7694
US

V. Phone/Fax

Practice location:
  • Phone: 731-885-8722
  • Fax: 731-885-4855
Mailing address:
  • Phone: 731-885-8722
  • Fax: 731-885-4855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number105619
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: