Healthcare Provider Details

I. General information

NPI: 1710168927
Provider Name (Legal Business Name): ALLISON SUE DOMER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13218 BROOKLANE DR
HAGERSTOWN MD
21742-1435
US

IV. Provider business mailing address

13218 BROOKLANE DR
HAGERSTOWN MD
21742-1435
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0331
  • Fax: 301-733-4038
Mailing address:
  • Phone: 301-733-0331
  • Fax: 301-733-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR100629
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: