Provider Demographics
NPI:1073281754
Name:DOMINGO, LEO ERNIE MANANGAN (NP)
Entity Type:Individual
Prefix:
First Name:LEO ERNIE
Middle Name:MANANGAN
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4906
Mailing Address - Country:US
Mailing Address - Phone:619-888-3089
Mailing Address - Fax:
Practice Address - Street 1:200 FREEDOM LANE
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656
Practice Address - Country:US
Practice Address - Phone:877-476-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA827301163WP0808X
CA95018365363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health