Healthcare Provider Details

I. General information

NPI: 1467091827
Provider Name (Legal Business Name): DOMINIC DALATEN LOMIBAO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 4TH AVE STE 14
CHULA VISTA CA
91910-3813
US

IV. Provider business mailing address

9360 MONONA DR
LA MESA CA
91942-3910
US

V. Phone/Fax

Practice location:
  • Phone: 619-303-3681
  • Fax:
Mailing address:
  • Phone: 619-303-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95013019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: