Provider Demographics
NPI:1043885064
Name:DOMINGUEZ, MARIA CONNIE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:CONNIE
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 1:4500 SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75210-1350
Mailing Address - Country:US
Mailing Address - Phone:214-865-3060
Mailing Address - Fax:
Practice Address - Street 1:4500 SPRING AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75210-1350
Practice Address - Country:US
Practice Address - Phone:214-860-3077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2259172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker