Provider Demographics
NPI:1780184317
Name:DOMINGO, ATINUKE ANTHONIA
Entity Type:Individual
Prefix:
First Name:ATINUKE
Middle Name:ANTHONIA
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22135 LEIROP DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2974
Mailing Address - Country:US
Mailing Address - Phone:832-228-5997
Mailing Address - Fax:
Practice Address - Street 1:22135 LEIROP DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2974
Practice Address - Country:US
Practice Address - Phone:832-228-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220512164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20-407791OtherMEDCARE PEDIATRIC NURSING LP