Provider Demographics
NPI:1164978193
Name:DIDOMENICO, NICOLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5054 KELSO ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2390
Mailing Address - Country:US
Mailing Address - Phone:757-358-0511
Mailing Address - Fax:
Practice Address - Street 1:3935 SUNNYSIDE DR
Practice Address - Street 2:A
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-2328
Practice Address - Country:US
Practice Address - Phone:540-568-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007413235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist