Individual
KELLIE LYNN DOMINESSY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C, MMS, ATC
Contact information
Practice address
2307 W BROWARD BLVD, STE 200, FORT LAUDERDALE, FL 33312-1417
(954) 792-1010
(954) 792-1199
Mailing address
2307 W BROWARD BLVD, STE 200, FORT LAUDERDALE, FL 33312-1417
(954) 792-1010
(954) 792-1199
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA9105661
FL
363AS0400X
Surgical Physician Assistant
Primary
PA9105661
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003180000
—
FL
01
—
Y06HZ
BCBS
FL
Enumeration date
12/28/2010
Last updated
03/28/2016
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