Kellie Lynn Dominessy, PA-C, MMS, ATC

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

PA9105661 Issued in FL

Practice address

2307 W Broward Blvd
Ste 200
Fort Lauderdale, FL 33312-1417

Phone

(954) 792-1010

Fax

(954) 792-1199

NPI assigned

Dec 28, 2010

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kdominessy2020533@direct.trinity-health.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Holy Cross Hospital Inc

  dba Holy Cross Medical Group

  • Internal Medicine Physician
  • Fort Lauderdale, FL
  • NPI 1467401877
  Medicare reassignment NPD
• Holy Cross Hospital, Inc

  dba Holy Cross Diabetes Prevention Program

  • Health & Wellness Coach
  • Oakland Park, FL
  • NPI 1063207595
  NPD
• Nsi Broward LLC

  • General Practice Physician
  • Weston, FL
  • NPI 1295203784
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1293494400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1459123200000",
    "number": "1932403383",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2307 W BROWARD BLVD",
            "address_2": "STE 200",
            "city": "FORT LAUDERDALE",
            "state": "FL",
            "postal_code": "333121417",
            "telephone_number": "954-792-1010",
            "fax_number": "954-792-1199"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2307 W BROWARD BLVD",
            "address_2": "STE 200",
            "city": "FORT LAUDERDALE",
            "state": "FL",
            "postal_code": "333121417",
            "telephone_number": "954-792-1010",
            "fax_number": "954-792-1199"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOMINESSY",
        "first_name": "KELLIE",
        "middle_name": "LYNN",
        "credential": "PA-C, MMS, ATC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-12-28",
        "last_updated": "2016-03-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9105661",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "FL",
            "license": "PA9105661",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003180000",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "Y06HZ",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Louise Dolce
• Michael Dolchin, MD
• Liz-Aesha Dollisen
• Loraine Domado, PT
• James Domesek, MD
• Dominga's Therapy Services PTR PA
• Dominga's Therapy Services PTR. PA.
• Mayelin Dominguez Milian
• Caroline Lydia Dominguez
• Erick Dominguez

• Surgical Physician Assistant in Fort Lauderdale, FL
• Providers in Fort Lauderdale, FL by specialty
• Surgical Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.