MEDICARE: MRS. DEANNA DOMNISCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305208347	VA
2	225100000X	Physical Therapist	PT871510	DC
3	225100000X	Physical Therapist	PT38897	FL

General Provider Information

NPI Number	:	1396174017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEANNA DOMNISCH

Provider Business Mailing Address
First Line	:	4711 S HIMES AVE APT 801
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-2622
Country	:	US
Telephone Number	:	716-696-0212
Fax Number	:

Provider Business Practice Location Address
First Line	:	2307 S DALE MABRY HWY STE F
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-6322
Country	:	US
Telephone Number	:	813-374-9508
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	07/11/2022

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