Provider Demographics
NPI:1811374408
Name:DOMINO, RACHAEL (NP)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43268 RAFTINGWAY CT
Mailing Address - Street 2:APT 2808
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-7453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-03
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308016363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care