Provider Demographics
NPI:1710984141
Name:DOMM, MARY ANN PENNY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:PENNY
Last Name:DOMM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 SW APPLE WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1772
Mailing Address - Country:US
Mailing Address - Phone:503-477-7222
Mailing Address - Fax:503-894-9699
Practice Address - Street 1:8550 SW APPLE WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1772
Practice Address - Country:US
Practice Address - Phone:503-477-7222
Practice Address - Fax:503-894-9699
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU62575Medicare UPIN
ORR0000QGHHKMedicare ID - Type Unspecified