Provider Demographics
NPI:1437272655
Name:DOMINGUEZ, ILIA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:ILIA
Middle Name:M
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:RN
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 962
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-0962
Mailing Address - Country:US
Mailing Address - Phone:787-241-8886
Mailing Address - Fax:
Practice Address - Street 1:AVE AGUSTIN RAMOS CALERO INT 111 BZN 737
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662
Practice Address - Country:US
Practice Address - Phone:787-830-2765
Practice Address - Fax:787-830-0465
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12514163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse