Provider Demographics
NPI:1396174017
Name:DOMNISCH, DEANNA
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:
Last Name:DOMNISCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:FAVERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4711 S HIMES AVE APT 801
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2622
Mailing Address - Country:US
Mailing Address - Phone:716-696-0212
Mailing Address - Fax:
Practice Address - Street 1:2307 S DALE MABRY HWY STE F
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6322
Practice Address - Country:US
Practice Address - Phone:813-374-9508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208347225100000X
DCPT871510225100000X
FLPT38897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist