Provider Demographics
NPI:1689788143
Name:DOMINO, AGGIE (RD,LDN)
Entity Type:Individual
Prefix:
First Name:AGGIE
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 MENLO DR APT 5
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-5685
Mailing Address - Country:US
Mailing Address - Phone:225-761-6700
Mailing Address - Fax:
Practice Address - Street 1:7968 ESSEN PARK
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-7439
Practice Address - Country:US
Practice Address - Phone:225-761-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1776133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered