Provider Demographics
NPI:1578173167
Name:DOMINICK, KYLIE GRAW
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:GRAW
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 S BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4807
Mailing Address - Country:US
Mailing Address - Phone:918-895-7680
Mailing Address - Fax:918-236-4646
Practice Address - Street 1:1025 PENNOCK PLACE
Practice Address - Street 2:
Practice Address - City:FORT COLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-495-8800
Practice Address - Fax:970-495-8891
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2025-05-15
Deactivation Date:2025-04-23
Deactivation Code:
Reactivation Date:2025-05-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS09061997OtherBIRTHDATE