Provider Demographics
NPI:1114596244
Name:DOMINGUEZ, AMANDA KRISTEN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KRISTEN
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 1:11005 NORRIS AVE # 43
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-2501
Mailing Address - Country:US
Mailing Address - Phone:818-480-1144
Mailing Address - Fax:
Practice Address - Street 1:11005 NORRIS AVE # 43
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-2501
Practice Address - Country:US
Practice Address - Phone:818-480-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
XEH910101639OtherBLUE SHIELD