MEDICARE: RACHAEL DOMINO NP

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	363LA2100X	Acute Care Nurse Practitioner	4704308016	MI

General Provider Information

NPI Number	:	1811374408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHAEL DOMINO NP

Provider Business Mailing Address
First Line	:	43268 RAFTINGWAY CT
Second Line	:	APT 2808
City	:	NOVI
State	:	MI
Zip	:	48375-5414
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22101 MOROSS RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48236-2148
Country	:	US
Telephone Number	:	313-343-7453
Fax Number	:

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

Provider Enumeration Date	:	05/03/2015
Last Update Date	:	05/03/2015

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