Provider Demographics
NPI:1477321370
Name:DOMERY, AMANDA CATHERINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
Last Name:DOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CATHERINE
Other - Last Name:NOHAVEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 EVELYN DR
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-9752
Mailing Address - Country:US
Mailing Address - Phone:617-780-4417
Mailing Address - Fax:
Practice Address - Street 1:52 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5176
Practice Address - Country:US
Practice Address - Phone:518-456-3268
Practice Address - Fax:518-464-1469
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY515035111246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other