Provider Demographics
NPI:1396391397
Name:DOMINGUEZ, SANTA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:SANTA
Middle Name:ANN
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:FNP
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 1563
Mailing Address - Street 2:
Mailing Address - City:AVALON
Mailing Address - State:CA
Mailing Address - Zip Code:90704-1563
Mailing Address - Country:US
Mailing Address - Phone:310-510-0096
Mailing Address - Fax:310-510-2381
Practice Address - Street 1:100 FALLS CANYON ROAD
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:CA
Practice Address - Zip Code:90704
Practice Address - Country:US
Practice Address - Phone:310-510-0096
Practice Address - Fax:310-510-2381
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily