Provider Demographics
NPI:1669851176
Name:DOMINGUEZ, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
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 1:3407 45TH ST
Mailing Address - Street 2:2FL
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1003
Mailing Address - Country:US
Mailing Address - Phone:718-637-9612
Mailing Address - Fax:
Practice Address - Street 1:3407 45TH ST
Practice Address - Street 2:2FL
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-1003
Practice Address - Country:US
Practice Address - Phone:718-637-9612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist