Healthcare Provider Details

I. General information

NPI: 1184665010
Provider Name (Legal Business Name): MICHELLE ANN DOMANCHUK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E SCHILLER ST SUITE 318
ELMHURST IL
60126-2858
US

IV. Provider business mailing address

1107 ARLINGTON AVE
LA GRANGE IL
60525-5811
US

V. Phone/Fax

Practice location:
  • Phone: 630-832-1775
  • Fax:
Mailing address:
  • Phone: 708-354-0332
  • Fax: 708-763-2162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-001363
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: