Active NPI
Nicole Domine, LICSW
- Clinical Social Worker
- Fargo, ND
National Provider Identifier
1396280954
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 5293
- Practice address
- 4357 13TH Ave S Ste 104
Fargo, ND 58103-7504 - Phone
- (701) 478-4480
- Fax
- (701) 478-4481
- NPI assigned
- Jan 5, 2017
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 23025 | MN | |
| Clinical Social Worker | 1041C0700X | 5293 | ND | Primary |
Addresses
Primary practice location
4357 13TH Ave S Ste 104
Fargo, ND 58103-7504
Mailing address
4357 13TH Ave S Ste 104
Fargo, ND 58103-7504
Phone (701) 478-4480
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5293 | ND | MD | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1483574400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1732233600000",
"number": "1396280954",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4357 13TH AVE S STE 104",
"city": "FARGO",
"state": "ND",
"postal_code": "581037504",
"telephone_number": "701-478-4480",
"fax_number": "701-478-4481"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4357 13TH AVE S STE 104",
"city": "FARGO",
"state": "ND",
"postal_code": "581037504",
"telephone_number": "701-478-4480",
"fax_number": "701-478-4481"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOMINE",
"first_name": "NICOLE",
"credential": "LICSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2017-01-05",
"last_updated": "2024-11-22",
"certification_date": "2024-11-22",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MN",
"license": "23025",
"primary": false
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "ND",
"license": "5293",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fargo, ND
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.