Provider Demographics
NPI:1255386181
Name:DOMINGUEZ, DONNA L (APN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PRINGLE WAY
Mailing Address - Street 2:SUITE 705
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1464
Mailing Address - Country:US
Mailing Address - Phone:775-329-0333
Mailing Address - Fax:
Practice Address - Street 1:75 PRINGLE WAY
Practice Address - Street 2:SUITE 705
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1464
Practice Address - Country:US
Practice Address - Phone:775-329-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN00537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002416003Medicaid
NV880167036A018OtherTRICARE
NVNV6094OtherBLUE CROSS BLUE SHIELD
NVP50458Medicare UPIN
NV32586Medicare ID - Type Unspecified
NV500026799Medicare ID - Type UnspecifiedRR MEDICARE