Provider Demographics
NPI:1174788145
Name:DOMINICK, JOANNA BETH (DNP, PMHNP-BC, FNP-C)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:BETH
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 SUTTLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303
Mailing Address - Country:US
Mailing Address - Phone:970-444-2429
Mailing Address - Fax:630-647-4726
Practice Address - Street 1:72 SUTTLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303
Practice Address - Country:US
Practice Address - Phone:970-444-2429
Practice Address - Fax:630-647-4726
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.005295-NP363LF0000X, 363LP0808X
NMAPN.005295-NP363LF0000X, 363LP0808X
CO5295363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03481841Medicaid
CO03481841Medicaid