Healthcare Provider Details

I. General information

NPI: 1205382983
Provider Name (Legal Business Name): HAROLYN DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 NW 177TH ST APT 103
HIALEAH FL
33015-6236
US

IV. Provider business mailing address

7250 NW 177TH ST APT 103
HIALEAH FL
33015-6236
US

V. Phone/Fax

Practice location:
  • Phone: 305-200-2086
  • Fax:
Mailing address:
  • Phone: 305-200-2086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberD552320948790
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: