Provider Demographics
NPI:1891220810
Name:FERTAL, DOMINIQUE S (CRNA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:S
Last Name:FERTAL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:S
Other - Last Name:STRYKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 604
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-1385
Mailing Address - Fax:
Practice Address - Street 1:350 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1731
Practice Address - Country:US
Practice Address - Phone:585-919-2668
Practice Address - Fax:585-396-6455
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN656120163W00000X, 367500000X
NY629842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse