Healthcare Provider Details

I. General information

NPI: 1356421051
Provider Name (Legal Business Name): PAMELA S DOMINO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 SONOMA AVE
SANTA ROSA CA
95404
US

IV. Provider business mailing address

983 SONOMA AVE
SANTA ROSA CA
95404
US

V. Phone/Fax

Practice location:
  • Phone: 707-583-8700
  • Fax: 707-303-4066
Mailing address:
  • Phone: 707-583-8700
  • Fax: 707-303-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number533902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: