Provider Demographics
NPI:1770022899
Name:DOMINGUEZ PICENO, MARTHA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:DOMINGUEZ PICENO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E. ALMOND AVE.
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637
Mailing Address - Country:US
Mailing Address - Phone:559-675-5555
Mailing Address - Fax:
Practice Address - Street 1:1250 E. ALMOND AVE.
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637
Practice Address - Country:US
Practice Address - Phone:559-675-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily