Provider Demographics
NPI:1447442017
Name:DOMINGO, MYRNA B (NP)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:B
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 CLINTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2452
Mailing Address - Country:US
Mailing Address - Phone:201-439-0347
Mailing Address - Fax:212-342-8598
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:7 TOWER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3784
Practice Address - Country:US
Practice Address - Phone:212-342-8600
Practice Address - Fax:212-342-8598
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350239-1363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal