Provider Demographics
NPI:1043635162
Name:DOMINGO, ALODIA BANUELOS (NP)
Entity type:Individual
Prefix:
First Name:ALODIA
Middle Name:BANUELOS
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALODIA
Other - Middle Name:
Other - Last Name:BANUELOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5700 W OLIVE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3147
Mailing Address - Country:US
Mailing Address - Phone:623-738-6062
Mailing Address - Fax:602-354-9462
Practice Address - Street 1:5700 W OLIVE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:623-738-6062
Practice Address - Fax:602-354-9462
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN135342163W00000X
AZAP5625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse