Provider Demographics
NPI:1184665010
Name:DOMANCHUK, MICHELLE ANN (APN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:DOMANCHUK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5811
Mailing Address - Country:US
Mailing Address - Phone:708-354-0332
Mailing Address - Fax:708-763-2162
Practice Address - Street 1:110 E SCHILLER ST
Practice Address - Street 2:SUITE 318
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2858
Practice Address - Country:US
Practice Address - Phone:630-832-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001363363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL800012875OtherRAILROAD MEDICARE
ILP34853Medicare UPIN
IL709650Medicare ID - Type Unspecified