Provider Demographics
NPI:1689974271
Name:DOMINICK, SUSAN B (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6239 PITTSFORD PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3123
Mailing Address - Country:US
Mailing Address - Phone:585-223-7847
Mailing Address - Fax:585-223-5137
Practice Address - Street 1:6239 PITTSFORD PALMYRA RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3123
Practice Address - Country:US
Practice Address - Phone:585-223-7847
Practice Address - Fax:585-223-5137
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY482354163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse