Provider Demographics
NPI:1700123494
Name:DOMINGUEZ, NATALIE ADA (RN)
Entity Type:Individual
Prefix:MRS
First Name:NATALIE
Middle Name:ADA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:HWY 160/163 BUILDING KA-2010
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:928-697-4100
Mailing Address - Fax:928-697-4029
Practice Address - Street 1:HWY 160/163 BUILDING KA-2010
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0368
Practice Address - Country:US
Practice Address - Phone:928-697-4100
Practice Address - Fax:928-697-4029
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN175037163W00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060012Medicaid
AZHSZ045Medicare PIN