Provider Demographics
NPI:1841819661
Name:DOMINGO, CHRISTINE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
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 1:2072 KAMAILE ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-5457
Mailing Address - Country:US
Mailing Address - Phone:808-285-7803
Mailing Address - Fax:
Practice Address - Street 1:81 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1723
Practice Address - Country:US
Practice Address - Phone:808-285-7803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-11
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIEL-45246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty