Provider Demographics
NPI:1609042878
Name:DOMINGUEZ, EDDY (APRN)
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 W 52ND ST APT 103
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4771
Mailing Address - Country:US
Mailing Address - Phone:786-290-3277
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:4175 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-825-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily