Provider Demographics
NPI:1043830441
Name:DOMER, MYIAH NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:MYIAH
Middle Name:NICOLE
Last Name:DOMER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 POLARIS PKWY
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7971
Mailing Address - Country:US
Mailing Address - Phone:614-545-7900
Mailing Address - Fax:614-545-7901
Practice Address - Street 1:340 POLARIS PKWY
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7971
Practice Address - Country:US
Practice Address - Phone:614-839-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0360577Medicaid