Provider Demographics
NPI:1568195147
Name:DOMINICCI, BRIAN KEITH (LPN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:DOMINICCI
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER RD STE 300
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2302
Practice Address - Country:US
Practice Address - Phone:503-941-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201909621LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse