Provider Demographics
NPI:1407182439
Name:DOMINGUEZ, INOCENCIA
Entity Type:Individual
Prefix:MS
First Name:INOCENCIA
Middle Name:
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 1:835 BORDENTOWN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-1416
Mailing Address - Country:US
Mailing Address - Phone:848-203-9487
Mailing Address - Fax:
Practice Address - Street 1:530 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3654
Practice Address - Country:US
Practice Address - Phone:732-324-5042
Practice Address - Fax:732-324-3121
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01109000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist