Provider Demographics
NPI:1447893128
Name:DOMINGUEZ, KELLI D (NP-C)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:D
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 GOLF COURSE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5019
Mailing Address - Country:US
Mailing Address - Phone:505-727-8000
Mailing Address - Fax:
Practice Address - Street 1:10501 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5019
Practice Address - Country:US
Practice Address - Phone:505-727-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM58658363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily