Provider Demographics
NPI:1932309101
Name:SPARAGO, DOMENICA ELISE (LPN)
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:ELISE
Last Name:SPARAGO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2921
Mailing Address - Country:US
Mailing Address - Phone:516-765-0388
Mailing Address - Fax:
Practice Address - Street 1:1109 N BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1504
Practice Address - Country:US
Practice Address - Phone:516-448-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284307-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse