Provider Demographics
NPI:1609521301
Name:DOMKAM, ADELINE (FNP)
Entity type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:DOMKAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W MARCH LN STE 101
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-6568
Mailing Address - Country:US
Mailing Address - Phone:209-472-7100
Mailing Address - Fax:
Practice Address - Street 1:3031 W MARCH LN STE 101
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6568
Practice Address - Country:US
Practice Address - Phone:209-472-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF01220784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily