Healthcare Provider Details

I. General information

NPI: 1932934106
Provider Name (Legal Business Name): IRENE MERCEDES DOMINGUEZ PRENDES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/09/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 SW 97TH CT
MIAMI FL
33165-7270
US

IV. Provider business mailing address

5430 SW 97TH CT
MIAMI FL
33165-7270
US

V. Phone/Fax

Practice location:
  • Phone: 305-496-7549
  • Fax:
Mailing address:
  • Phone: 305-496-7549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number9286501
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11034477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: