Provider Demographics
NPI:1740768498
Name:DOMINGUEZ, ELIZABETH RUTH (LVN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RUTH
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 PEAVY SWITCH RD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7396
Mailing Address - Country:US
Mailing Address - Phone:469-386-9427
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST STE 608
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5756
Practice Address - Country:US
Practice Address - Phone:903-705-0070
Practice Address - Fax:903-405-3932
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228182164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty