MEDICARE: MICHELLE MARIE DOMMERMUTH 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	363LP0200X	Pediatric Nurse Practitioner	95005476	CA

General Provider Information

NPI Number	:	1841732351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MARIE DOMMERMUTH NP

Provider Business Mailing Address
First Line	:	441 E YOSEMITE AVE
Second Line	:
City	:	MADERA
State	:	CA
Zip	:	93638-3604
Country	:	US
Telephone Number	:	559-664-4000
Fax Number	:	559-675-5224

Provider Business Practice Location Address
First Line	:	441 E YOSEMITE AVE
Second Line	:
City	:	MADERA
State	:	CA
Zip	:	93638-3604
Country	:	US
Telephone Number	:	559-664-4000
Fax Number	:	559-675-5224

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

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	09/16/2022

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