Provider Demographics
NPI:1770742181
Name:DIDOMENICO, CONCETTA (PNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CONCETTA
Middle Name:
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 S CARLISLE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-3925
Mailing Address - Country:US
Mailing Address - Phone:215-551-0809
Mailing Address - Fax:
Practice Address - Street 1:2236 S CARLISLE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-3925
Practice Address - Country:US
Practice Address - Phone:215-551-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006069N363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics