Provider Demographics
NPI:1407081318
Name:DIDOMENICO, MARY M (RN, MA, MED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:RN, MA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 RIDGELAND ROAD
Mailing Address - Street 2:COLONIAL HEIGHTS
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-2607
Mailing Address - Country:US
Mailing Address - Phone:914-346-8700
Mailing Address - Fax:
Practice Address - Street 1:29 RIDGELAND ROAD
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-2607
Practice Address - Country:US
Practice Address - Phone:914-346-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613352-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse