Provider Demographics
NPI:1396521241
Name:DOMINGUEZ ROMAN, RITA GENOVEVA (CHW2)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:GENOVEVA
Last Name:DOMINGUEZ ROMAN
Suffix:
Gender:F
Credentials:CHW2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6285 ANGORA PEAK LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-1662
Mailing Address - Country:US
Mailing Address - Phone:954-860-3216
Mailing Address - Fax:
Practice Address - Street 1:6285 ANGORA PEAK LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-1662
Practice Address - Country:US
Practice Address - Phone:954-860-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207Q00000X172V00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV193200000XOtherMULTI SPECIALTY-GROUP
NV207Q00000XOtherFAMILY MEDICINE