Healthcare Provider Details

I. General information

NPI: 1144086612
Provider Name (Legal Business Name): ANNA MARIA DOMALIK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N HIGHLAND AVE
AURORA IL
60506-1404
US

IV. Provider business mailing address

28594 NETWORK PL
CHICAGO IL
60673-1285
US

V. Phone/Fax

Practice location:
  • Phone: 630-264-8720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209028559
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209028559
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209028559
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: