Provider Demographics
NPI:1568015873
Name:DOMINGUEZ, SHAWNA L W (CNP)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNA
Middle Name:L W
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:
Practice Address - Street 1:1511 S LIME ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-6207
Practice Address - Country:US
Practice Address - Phone:575-544-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM56979363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE