Provider Demographics
NPI:1689681934
Name:DOMINGUEZ, DEBORAH ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:A
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:99 E RIVER DR FL 5
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-0833
Mailing Address - Fax:860-423-4694
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1956
Practice Address - Country:US
Practice Address - Phone:860-679-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002045367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004208767Medicaid
CT430000685Medicare ID - Type Unspecified