Provider Demographics
NPI:1710505482
Name:DOMINGUEZ, LISSETTE (APRN)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12159 SW 132ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:305-251-4989
Mailing Address - Fax:305-251-4990
Practice Address - Street 1:11126 NW 4TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3639
Practice Address - Country:US
Practice Address - Phone:059-109-5993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006296363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily