MEDICARE: THERESA ELIZABETH DOMINGUEZ RN IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	781135	TX
2	163WL0100X	Lactation Consultant (Registered Nurse)	L-166288	TX

General Provider Information

NPI Number	:	1396477030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA ELIZABETH DOMINGUEZ RN IBCLC

Provider Business Mailing Address
First Line	:	1621 LAKEVILLE DR STE 304
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77339-2694
Country	:	US
Telephone Number	:	281-305-0411
Fax Number	:

Provider Business Practice Location Address
First Line	:	12777 JONES RD STE 440
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4600
Country	:	US
Telephone Number	:	281-305-0411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	06/30/2022

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