Provider Demographics
NPI:1275778730
Name:DOMERACKI, SANDRA JO (NP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:JO
Last Name:DOMERACKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 LARKSPUR PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939
Mailing Address - Country:US
Mailing Address - Phone:415-221-4810
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:BUILDING 203, GB-31
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:415-750-2249
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily