Provider Demographics
NPI:1881275261
Name:MADE, DOMINGA
Entity type:Individual
Prefix:
First Name:DOMINGA
Middle Name:
Last Name:MADE
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 1:3019 LONESOME RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-4894
Mailing Address - Country:US
Mailing Address - Phone:813-446-1298
Mailing Address - Fax:
Practice Address - Street 1:2912 MANGUM RD UNIT A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-7408
Practice Address - Country:US
Practice Address - Phone:832-740-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1033925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily