Provider Demographics
NPI:1003415563
Name:DOMINGUEZ, SANJUANITA
Entity Type:Individual
Prefix:
First Name:SANJUANITA
Middle Name:
Last Name:DOMINGUEZ
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 1:875 34TH AVE E APT 314
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8051
Mailing Address - Country:US
Mailing Address - Phone:701-885-1868
Mailing Address - Fax:
Practice Address - Street 1:875 34TH AVE E APT 314
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8051
Practice Address - Country:US
Practice Address - Phone:701-885-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant