Provider Demographics
NPI:1235613803
Name:DOMINGO, ILUMINADA PERALTA (CNA)
Entity Type:Individual
Prefix:
First Name:ILUMINADA
Middle Name:PERALTA
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1177 HOOMAKOA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3723
Mailing Address - Country:US
Mailing Address - Phone:808-676-5188
Mailing Address - Fax:808-676-5188
Practice Address - Street 1:94-1177 HOOMAKOA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3723
Practice Address - Country:US
Practice Address - Phone:808-676-5188
Practice Address - Fax:808-676-5188
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-1000733747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI$$$$$$$$$Medicaid