Basic Information
| Provider Information | |||||||||
| NPI: | 1134172034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMIER | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R138036-3 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 041H1DO | 01 | MN | MNBS # | OTHER | 2003184 | 01 | MN | MEDICA # | OTHER | 49119 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 1134172034 | 05 | MN | MEDICAID | 26506 | 01 | MN | NDBS # | OTHER | 49119 | 01 | MN | LHS # | OTHER | HP42498 | 01 | MN | HEALTHPARTNERS # | OTHER | DA9031016140 | 01 | MN | PREFERRED ONE # | OTHER |