Healthcare Provider Details

I. General information

NPI: 1184676322
Provider Name (Legal Business Name): THERESA M DOMAGOLA ACNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 MAX LEGGETT PKWY STE 3600
JACKSONVILLE FL
32218-7279
US

IV. Provider business mailing address

15255 MAX LEGGETT PKWY STE 3600
JACKSONVILLE FL
32218-7279
US

V. Phone/Fax

Practice location:
  • Phone: 904-427-6895
  • Fax:
Mailing address:
  • Phone: 904-427-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number430210
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11002747
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: