Provider Demographics
NPI:1497204515
Name:DOMINIC, SHEILA VATTATHIL (FNP)
Entity Type:Individual
Prefix:MS
First Name:SHEILA
Middle Name:VATTATHIL
Last Name:DOMINIC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 ALICE ST APT 25
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-5002
Mailing Address - Country:US
Mailing Address - Phone:530-592-6691
Mailing Address - Fax:
Practice Address - Street 1:3451 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3463
Practice Address - Country:US
Practice Address - Phone:510-535-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner