Provider Demographics
NPI:1699969501
Name:DOMINICO, DIANE J (RIGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:DOMINICO
Suffix:
Gender:F
Credentials:RIGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 N COLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3064
Mailing Address - Country:US
Mailing Address - Phone:631-696-5694
Mailing Address - Fax:
Practice Address - Street 1:69 N COLEMAN RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3064
Practice Address - Country:US
Practice Address - Phone:631-696-5694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY444171-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse