Provider Demographics
NPI:1083984868
Name:DOMINSKI, KELLY (APNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DOMINSKI
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2409
Mailing Address - Country:US
Mailing Address - Phone:414-328-6000
Mailing Address - Fax:
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI170180-30163W00000X
WI5166363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083984868Medicaid
WIWI23007Medicare PIN