Provider Demographics
NPI:1174143044
Name:DOMINGOS, ALYSSA MARIE (APRN, FNP)
Entity type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:MARIE
Last Name:DOMINGOS
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:MISS
Other - First Name:ALYSSA
Other - Middle Name:MARIE
Other - Last Name:KANICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:815 SE RICE RD
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66607-2354
Mailing Address - Country:US
Mailing Address - Phone:785-559-5192
Mailing Address - Fax:
Practice Address - Street 1:815 SE RICE RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66607-2354
Practice Address - Country:US
Practice Address - Phone:785-559-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS79240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner