Provider Demographics
NPI:1689742694
Name:DOMINGO, GRACE RITA R (NP)
Entity Type:Individual
Prefix:MRS
First Name:GRACE RITA
Middle Name:R
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:GRACE
Other - Middle Name:R
Other - Last Name:DOMINGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:530 1ST AVE
Mailing Address - Street 2:SKI-9R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6497
Mailing Address - Country:US
Mailing Address - Phone:212-263-8177
Mailing Address - Fax:212-263-3988
Practice Address - Street 1:530 1ST AVE # SKI-9R
Practice Address - Street 2:LEON H CHARNEY DIVISION OF CARDIOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-8177
Practice Address - Fax:212-263-3988
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334785-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily