Provider Demographics
NPI:1053446195
Name:DOMINGUEZ, HANNAH JEAN MENDEZ
Entity Type:Individual
Prefix:MS
First Name:HANNAH JEAN
Middle Name:MENDEZ
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 1:400 MAPLE VALLEY DR
Mailing Address - Street 2:APT 6
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1979
Mailing Address - Country:US
Mailing Address - Phone:417-434-1344
Mailing Address - Fax:
Practice Address - Street 1:801 BRIM ST
Practice Address - Street 2:
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3441
Practice Address - Country:US
Practice Address - Phone:573-431-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032610225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist