Provider Demographics
NPI:1932403383
Name:DOMINESSY, KELLIE LYNN (PA-C, MMS, ATC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYNN
Last Name:DOMINESSY
Suffix:
Gender:F
Credentials:PA-C, MMS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W BROWARD BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1417
Mailing Address - Country:US
Mailing Address - Phone:954-792-1010
Mailing Address - Fax:954-792-1199
Practice Address - Street 1:2307 W BROWARD BLVD
Practice Address - Street 2:STE 200
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1417
Practice Address - Country:US
Practice Address - Phone:954-792-1010
Practice Address - Fax:954-792-1199
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105661363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003180000Medicaid
FLY06HZOtherBCBS
FL003180000Medicaid