Provider Demographics
NPI:1457339202
Name:DOMINGUEZ, MARITZA (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARITZA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 NASSAU RD
Mailing Address - Street 2:LONG ISLAND FQHC, INC.
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-571-8600
Mailing Address - Fax:
Practice Address - Street 1:101 S BERGEN PLACE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520
Practice Address - Country:US
Practice Address - Phone:516-623-3600
Practice Address - Fax:516-623-9191
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303551363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02481836Medicaid
NY02481836Medicaid
P69542Medicare UPIN