Provider Demographics
NPI:1508172636
Name:DOMZALSKI, NICOLE RENEE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RENEE
Last Name:DOMZALSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N. DOBSON RD
Mailing Address - Street 2:STE F-2
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-9611
Mailing Address - Country:US
Mailing Address - Phone:480-634-5440
Mailing Address - Fax:
Practice Address - Street 1:3200 N. DOBSON RD
Practice Address - Street 2:STE F-2
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-8522
Practice Address - Country:US
Practice Address - Phone:480-722-1300
Practice Address - Fax:480-422-3824
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6832235Z00000X
AZSLP6832235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty