Provider Demographics
NPI:1568444966
Name:DOMINGUEZ, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
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 1:10131 W. FOREST HILL BLVD
Mailing Address - Street 2:STE 230
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-798-6600
Mailing Address - Fax:561-204-2042
Practice Address - Street 1:440 N STATE ROAD 7 STE B
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3504
Practice Address - Country:US
Practice Address - Phone:561-798-6600
Practice Address - Fax:561-753-3328
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9458773163W00000X
246ZS0410X
FLAPRN11014312363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist