Provider Demographics
NPI:1972938231
Name:DOMENICO, KARAH NICOLE (RD)
Entity Type:Individual
Prefix:MISS
First Name:KARAH
Middle Name:NICOLE
Last Name:DOMENICO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PARK CENTRAL EAST STE. 217
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806
Mailing Address - Country:US
Mailing Address - Phone:417-619-7187
Mailing Address - Fax:
Practice Address - Street 1:205 PARK CENTRAL EAST STE. 217
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806
Practice Address - Country:US
Practice Address - Phone:417-619-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012032624133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered