Provider Demographics
NPI:1548797921
Name:DOMINGUE, MARIA GRACE (CNM)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GRACE
Last Name:DOMINGUE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5798 S GALLUP ST APT 105
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-2134
Mailing Address - Country:US
Mailing Address - Phone:303-587-1107
Mailing Address - Fax:
Practice Address - Street 1:180 E HAMPDEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2517
Practice Address - Country:US
Practice Address - Phone:303-789-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1633033163WP2201X
COAPN.0993226-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care