Provider Demographics
NPI:1366424921
Name:DOMINICK, JACQUELINE D (CRNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HOSPITAL DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6902
Mailing Address - Country:US
Mailing Address - Phone:410-787-4000
Mailing Address - Fax:410-787-4846
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR097460363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4457OtherBRAVO/ELDER HEALTH
MD127573OtherJOHNS HOPKINS HEALTH CARE
MD408588400Medicaid
DCF591-0020OtherCARE FIRST BLUE CROSS
MD64696401OtherCARE FIRST BLUE CROSS
MDKS04 M938Medicare PIN