Provider Demographics
NPI:1790319499
Name:DOMENA, ANGELINA M
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:M
Last Name:DOMENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WADDINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:13694-3100
Mailing Address - Country:US
Mailing Address - Phone:315-388-4299
Mailing Address - Fax:
Practice Address - Street 1:953 DANBY RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-7002
Practice Address - Country:US
Practice Address - Phone:607-274-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer