Basic Information
| Provider Information | |||||||||
| NPI: | 1255677480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORRADO | ||||||||
| FirstName: | DOMENICA | ||||||||
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| Credential: | RN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 POND RD | ||||||||
| Address2: | |||||||||
| City: | CORAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117273746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452835311 | ||||||||
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| Practice Location | |||||||||
| Address1: | MATHER HOSPITAL | ||||||||
| Address2: | 75 N COUNTRY ROAD | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2012 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/07/2016 | ||||||||
| NPIReactivationDate: | 06/27/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 344016 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 645874 | NY | N | Nursing Service Providers | Registered Nurse |
No ID Information.