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General NPI Number Information
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NPI Number | 1255615365
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Entity Type | Individual
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Provider Name | DOMINNO CAROLINE FOGLE M.M.S., PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/07/2011
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Last Update Date | 06/10/2024
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Provider Practice Location Address
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Address Line | 21660 W FIELD PKWY
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City | DEER PARK
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State | IL
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Zip | 60010-7265
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Country | US
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Telephone | 888-803-3370
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Fax |
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Provider Business Mailing Address
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Address Line | 271 COUNTY ROAD 2325 E
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City | CARLOCK
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State | IL
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Zip | 61725-9020
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Country | US
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Telephone | 815-931-0244
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085004161
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License Number State | IL
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