Provider Demographics
NPI:1437855699
Name:DOMINICK, MICHELE LEE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LEE
Other - Last Name:BOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:745 SHAWNEE LN
Mailing Address - Street 2:
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658-3635
Mailing Address - Country:US
Mailing Address - Phone:724-963-2858
Mailing Address - Fax:
Practice Address - Street 1:MEDMARK TREATMENT CENTER
Practice Address - Street 2:1037 COMPASS CIRCLE
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:724-834-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN290055164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse