Provider Demographics
NPI:1306351028
Name:DOMINICK, NICOLE LYN (CRNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYN
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 HIGHWAY 315 BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6952
Mailing Address - Country:US
Mailing Address - Phone:570-823-8896
Mailing Address - Fax:570-270-2692
Practice Address - Street 1:1130 HIGHWAY 315 BLVD STE 4
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6952
Practice Address - Country:US
Practice Address - Phone:570-823-8896
Practice Address - Fax:570-270-2692
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018244363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner