1174143044 NPI number — MRS. ALYSSA MARIE DOMINGOS APRN, FNP

Table of content: MRS. ALYSSA MARIE DOMINGOS APRN, FNP (NPI 1174143044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174143044 NPI number — MRS. ALYSSA MARIE DOMINGOS APRN, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGOS
Provider First Name:
ALYSSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KANICKI
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174143044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 SE RICE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66607-2354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-559-5192
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 SE RICE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66607-2354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-559-5096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  79240 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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