Healthcare Provider Details

I. General information

NPI: 1972996841
Provider Name (Legal Business Name): COURTNEY R DOMINGO WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY T RUBRIGHT

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16611 S 40TH ST SUITE 180
PHOENIX AZ
85048-0562
US

IV. Provider business mailing address

2545 W FRYE RD SUITE 9
CHANDLER AZ
85224-6273
US

V. Phone/Fax

Practice location:
  • Phone: 480-785-2100
  • Fax: 480-785-2111
Mailing address:
  • Phone: 480-505-4258
  • Fax: 480-275-8346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP7646
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: