Provider Demographics
NPI:1518336825
Name:DOMENECH, NICOLE A (MD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:A
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 S DOUGLAS RD
Mailing Address - Street 2:STE 308
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6134
Mailing Address - Country:US
Mailing Address - Phone:863-682-0843
Mailing Address - Fax:863-687-3971
Practice Address - Street 1:950 FIRST ST. SOUTH
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-295-5604
Practice Address - Fax:863-295-5398
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR19178208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice