Provider Demographics
NPI:1982104154
Name:DOMINGUEZ, ZORAIDA SOFIA
Entity Type:Individual
Prefix:
First Name:ZORAIDA
Middle Name:SOFIA
Last Name:DOMINGUEZ
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 1:652 MACCABE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6234
Mailing Address - Country:US
Mailing Address - Phone:702-861-7991
Mailing Address - Fax:
Practice Address - Street 1:1951 STELLA LAKE ST STE 36
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2144
Practice Address - Country:US
Practice Address - Phone:702-595-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17045513333747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1704551333Medicaid