Healthcare Provider Details

I. General information

NPI: 1114449030
Provider Name (Legal Business Name): KIMBERLY MARIE DOMALEWICZ FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 BURDETT AVE STE 110
TROY NY
12180-2447
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-271-3900
  • Fax: 518-271-3914
Mailing address:
  • Phone: 518-525-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number341343
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number341343
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: