Provider Demographics
NPI:1992022073
Name:DOMINICK-RIZEN, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:DOMINICK-RIZEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:DOMINICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2510 MARYLAND RD
Mailing Address - Street 2:STE #160
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1109
Mailing Address - Country:US
Mailing Address - Phone:215-672-6622
Mailing Address - Fax:
Practice Address - Street 1:2510 MARYLAND RD
Practice Address - Street 2:STE #160
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1109
Practice Address - Country:US
Practice Address - Phone:215-672-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD448802208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics