MEDICARE: KELLIE LYNN DOMINESSY PA-C, MMS, ATC

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	363A00000X	Physician Assistant	PA9105661	FL
2	363AS0400X	Surgical Physician Assistant	PA9105661	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	Y06HZ	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1932403383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE LYNN DOMINESSY PA-C, MMS, ATC

Provider Business Mailing Address
First Line	:	2307 W BROWARD BLVD
Second Line	:	STE 200
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1417
Country	:	US
Telephone Number	:	954-792-1010
Fax Number	:	954-792-1199

Provider Business Practice Location Address
First Line	:	2307 W BROWARD BLVD
Second Line	:	STE 200
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1417
Country	:	US
Telephone Number	:	954-792-1010
Fax Number	:	954-792-1199

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

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	03/28/2016

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