Basic Information
| Provider Information | |||||||||
| NPI: | 1366424921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINICK | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HOSPITAL DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210616902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107874000 | ||||||||
| FaxNumber: | 4107874846 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107874000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R097460 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 4457 | 01 | MD | BRAVO/ELDER HEALTH | OTHER | 127573 | 01 | MD | JOHNS HOPKINS HEALTH CARE | OTHER | 408588400 | 05 | MD | MEDICAID | F591-0020 | 01 | DC | CARE FIRST BLUE CROSS | OTHER | 64696401 | 01 | MD | CARE FIRST BLUE CROSS | OTHER |