Provider Demographics
NPI:1720036502
Name:DOMINGO, KRISTEN T (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:T
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 TIERRA DEL REY
Mailing Address - Street 2:#C
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7875
Mailing Address - Country:US
Mailing Address - Phone:619-656-5102
Mailing Address - Fax:619-656-5143
Practice Address - Street 1:1055 TIERRA DEL REY
Practice Address - Street 2:#C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7875
Practice Address - Country:US
Practice Address - Phone:619-656-5102
Practice Address - Fax:619-656-5143
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT30280AMedicare ID - Type Unspecified