Healthcare Provider Details

I. General information

NPI: 1891420717
Provider Name (Legal Business Name): BRITTANY AMBER DOMINGUEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5528 NW 43RD ST
GAINESVILLE FL
32653-3301
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-7011
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-3604
  • Fax: 352-627-4892
Mailing address:
  • Phone: 352-627-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11020700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: