Provider Demographics
NPI:1427590751
Name:DOMANICO, STEFANIE (CRNA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:DOMANICO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:BURDALAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2544 SPINDLEHILL DR
Mailing Address - Street 2:APT 5
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-1047
Mailing Address - Country:US
Mailing Address - Phone:248-515-3507
Mailing Address - Fax:
Practice Address - Street 1:2544 SPINDLEHILL DR
Practice Address - Street 2:APT 5
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230
Practice Address - Country:US
Practice Address - Phone:248-515-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292372367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered