Provider Demographics
NPI:1619536596
Name:DIDOMENICO, VICTORIA ANGELA (LPN)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:ANGELA
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ANGELA
Other - Last Name:GRISANTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4364 PRINCESS PATH
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-751-4687
Mailing Address - Fax:
Practice Address - Street 1:4364 PRINCESS PATH
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-751-4687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247270-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse