Provider Demographics
NPI:1871372797
Name:DOMINGUEZ, PRISCILLA (FNP-C)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4004
Mailing Address - Country:US
Mailing Address - Phone:818-356-5351
Mailing Address - Fax:
Practice Address - Street 1:618 S BRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4004
Practice Address - Country:US
Practice Address - Phone:818-356-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily