Healthcare Provider Details

I. General information

NPI: 1841732351
Provider Name (Legal Business Name): MICHELLE MARIE DOMMERMUTH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 E YOSEMITE AVE
MADERA CA
93638-3604
US

IV. Provider business mailing address

441 E YOSEMITE AVE
MADERA CA
93638-3604
US

V. Phone/Fax

Practice location:
  • Phone: 559-664-4000
  • Fax: 559-675-5224
Mailing address:
  • Phone: 559-664-4000
  • Fax: 559-675-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95005476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: