Healthcare Provider Details

I. General information

NPI: 1528756673
Provider Name (Legal Business Name): DOMENICA CAMACI-DOULEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 06/26/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-4644
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2440
  • Fax: 217-258-2186
Mailing address:
  • Phone: 217-868-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209027636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: