Healthcare Provider Details

I. General information

NPI: 1386222685
Provider Name (Legal Business Name): CASSIDY LOUISE DOMAGALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 OAK ST
PEORIA IL
61602-1639
US

IV. Provider business mailing address

817 NORMAL AVE
NORMAL IL
61761-1531
US

V. Phone/Fax

Practice location:
  • Phone: 309-690-7790
  • Fax: 866-385-4948
Mailing address:
  • Phone: 708-516-4718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number051.296273
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: