Provider Demographics
NPI:1679069249
Name:DOMINO, SARAH GRACE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:GRACE
Last Name:DOMINO
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 1:6283 ALAN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7647
Mailing Address - Country:US
Mailing Address - Phone:662-444-0312
Mailing Address - Fax:
Practice Address - Street 1:1007 WINDOVER RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6007
Practice Address - Country:US
Practice Address - Phone:870-520-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine