Provider Demographics
NPI:1336659978
Name:DOMINA, HEATHER L (DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:DOMINA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:LUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:111 GRATIOT DR
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7713
Mailing Address - Country:US
Mailing Address - Phone:315-406-3045
Mailing Address - Fax:
Practice Address - Street 1:750 SE CARY PKWY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5682
Practice Address - Country:US
Practice Address - Phone:919-651-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP11409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist