Provider Demographics
NPI:1891302386
Name:DOMINECK, DEANNA
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:DOMINECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 LORD NELSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6755
Mailing Address - Country:US
Mailing Address - Phone:904-469-9766
Mailing Address - Fax:
Practice Address - Street 1:913 LORD NELSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6755
Practice Address - Country:US
Practice Address - Phone:904-469-9766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL236905251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health