Healthcare Provider Details

I. General information

NPI: 1336890466
Provider Name (Legal Business Name): ASTON DOMMEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ST
FORT BRAGG NC
28310-7394
US

IV. Provider business mailing address

1620 12TH ST S APT D
BIRMINGHAM AL
35205-5929
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-7136
  • Fax:
Mailing address:
  • Phone: 717-269-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number3013
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: