Provider Demographics
NPI:1457631731
Name:DOMINGUEZ, EVELYN D
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:D
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 1:133 N SUNOL DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-1429
Mailing Address - Country:US
Mailing Address - Phone:323-368-2516
Mailing Address - Fax:
Practice Address - Street 1:133 N SUNOL DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063
Practice Address - Country:US
Practice Address - Phone:323-368-2516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker