Healthcare Provider Details

I. General information

NPI: 1821151143
Provider Name (Legal Business Name): DOMINIQUE M. LY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAITHAO KHANH DINH FNP

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7933 WREN AVE SUITE D
GILROY CA
95020-4996
US

IV. Provider business mailing address

1691 THE ALAMEDA
SAN JOSE CA
95126-2203
US

V. Phone/Fax

Practice location:
  • Phone: 408-847-1739
  • Fax: 408-847-5146
Mailing address:
  • Phone: 408-287-7532
  • Fax: 408-287-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 15986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: