Provider Demographics
NPI:1477929875
Name:DOMINGUEZ, SUSANA
Entity Type:Individual
Prefix:MS
First Name:SUSANA
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:PO BOX 1778
Mailing Address - Street 2:16700 5TH ST
Mailing Address - City:HURON
Mailing Address - State:CA
Mailing Address - Zip Code:93234-1778
Mailing Address - Country:US
Mailing Address - Phone:559-904-9337
Mailing Address - Fax:
Practice Address - Street 1:3333 E AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93725-9247
Practice Address - Country:US
Practice Address - Phone:559-600-4878
Practice Address - Fax:559-600-7645
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator