Healthcare Provider Details

I. General information

NPI: 1376575282
Provider Name (Legal Business Name): LARISSA F DOMINY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 SECOND AVE STE 303
COLLEGEVILLE PA
19426-3662
US

IV. Provider business mailing address

409 SECOND AVE STE 303
COLLEGEVILLE PA
19426-3662
US

V. Phone/Fax

Practice location:
  • Phone: 610-409-8050
  • Fax: 610-409-8075
Mailing address:
  • Phone: 610-409-8050
  • Fax: 610-409-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS-009162L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: