Provider Demographics
NPI:1225026941
Name:DOMINO, EDNA (APRN)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 WINKLER AVE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9523
Mailing Address - Country:US
Mailing Address - Phone:239-277-7070
Mailing Address - Fax:239-277-7071
Practice Address - Street 1:3033 WINKLER AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9523
Practice Address - Country:US
Practice Address - Phone:239-277-7070
Practice Address - Fax:239-277-7071
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1649932207X00000X
FLAPRN1649932363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ31340Medicare UPIN
FLY061CYMedicare ID - Type UnspecifiedMEDICARE PPIN