Provider Demographics
NPI:1942457965
Name:DOMENY, MICHAL (LAC, CD/N)
Entity Type:Individual
Prefix:MR
First Name:MICHAL
Middle Name:
Last Name:DOMENY
Suffix:
Gender:M
Credentials:LAC, CD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 402 BOX 1314
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-0014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:678 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1132
Practice Address - Country:US
Practice Address - Phone:347-693-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006241-1133N00000X
NY003443-1171100000X
NY337835363LA2200X
NY645452-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171100000XOther Service ProvidersAcupuncturist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner