Provider Demographics
NPI:1144612763
Name:DOMOSH, RUCHOMA A (APN, RN)
Entity Type:Individual
Prefix:MRS
First Name:RUCHOMA
Middle Name:A
Last Name:DOMOSH
Suffix:
Gender:F
Credentials:APN, RN
Other - Prefix:
Other - First Name:RUCHOMA
Other - Middle Name:AVIGAIL
Other - Last Name:KAGANOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109A RENA LN
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5290
Mailing Address - Country:US
Mailing Address - Phone:646-942-8882
Mailing Address - Fax:
Practice Address - Street 1:37 W 26TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1006
Practice Address - Country:US
Practice Address - Phone:212-696-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15036700363LP0200X
NY682398163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics