=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629605787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILLIAN DOMINGUEZ-KONICKI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2020
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEDICAL CENTER DR
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03756-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-650-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 WESTGATE RD
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02864-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207U00000X
-----------------------------------------------------
Taxonomy Name | Nuclear Medicine Physician
-----------------------------------------------------
License Number | 34594
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------