Provider Demographics
NPI:1295405371
Name:DOMEL, HEATHER BROOKE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:BROOKE
Last Name:DOMEL
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-0587
Mailing Address - Country:US
Mailing Address - Phone:361-239-5015
Mailing Address - Fax:361-239-5014
Practice Address - Street 1:207 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SHINER
Practice Address - State:TX
Practice Address - Zip Code:77984-5873
Practice Address - Country:US
Practice Address - Phone:361-239-5015
Practice Address - Fax:361-239-5014
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1052400363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner