Provider Demographics
NPI:1265491146
Name:DOMINGUEZ, LINDA (CNP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 LEAD AVE SE
Mailing Address - Street 2:STE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3644
Mailing Address - Country:US
Mailing Address - Phone:505-843-7131
Mailing Address - Fax:505-246-9421
Practice Address - Street 1:883 LEAD AVENUE SE SUITE A
Practice Address - Street 2:
Practice Address - City:ALB
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-843-7131
Practice Address - Fax:505-246-9421
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR20342363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91447Medicaid
NM91447Medicaid
NM343612201Medicare PIN