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General NPI Number Information
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NPI Number | 1184665010
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Entity Type | Individual
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Provider Name | MICHELLE ANN DOMANCHUK APN
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Gender | Female
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 08/22/2008
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Provider Practice Location Address
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Address Line | 110 E SCHILLER ST SUITE 318
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City | ELMHURST
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State | IL
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Zip | 60126-2858
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Country | US
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Telephone | 630-832-1775
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Fax |
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Provider Business Mailing Address
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Address Line | 1107 ARLINGTON AVE
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City | LA GRANGE
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State | IL
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Zip | 60525-5811
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Country | US
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Telephone | 708-354-0332
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Fax | 708-763-2162
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209-001363
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License Number State | IL
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