Provider Demographics
NPI:1184676322
Name:DOMAGOLA, THERESA M (ACNP C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:DOMAGOLA
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Gender:F
Credentials:ACNP C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2365 S CLINTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2663
Mailing Address - Country:US
Mailing Address - Phone:585-442-5320
Mailing Address - Fax:585-442-5526
Practice Address - Street 1:101 CANAL LANDING BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-5109
Practice Address - Country:US
Practice Address - Phone:585-239-7300
Practice Address - Fax:585-227-7723
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-07-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY430210363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601196Medicaid
70008ARA6884OtherMCR
70008ARA6884OtherMCR
NY02601196Medicaid