Healthcare Provider Details

I. General information

NPI: 1437855699
Provider Name (Legal Business Name): MICHELE LEE DOMINICK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELE LEE BOLIN LPN

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDMARK TREATMENT CENTER 1037 COMPASS CIRCLE
GREENSBURG PA
15601
US

IV. Provider business mailing address

745 SHAWNEE LN
LIGONIER PA
15658-3635
US

V. Phone/Fax

Practice location:
  • Phone: 724-834-1144
  • Fax:
Mailing address:
  • Phone: 724-963-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN290055
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: