Provider Demographics
NPI:1659907178
Name:DOMINGUEZ BAUTE, ILEANA (PMHNP)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:DOMINGUEZ BAUTE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14707 SOUTH DIXIE HIGHWAY, PALMETTO BAY, FL, 33176
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3039
Mailing Address - Country:US
Mailing Address - Phone:786-250-3475
Mailing Address - Fax:
Practice Address - Street 1:3030 SW 96TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3039
Practice Address - Country:US
Practice Address - Phone:786-419-0994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006611363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily