Healthcare Provider Details

I. General information

NPI: 1629910351
Provider Name (Legal Business Name): CHRISTOPHER OMAR DOMINGUEZ CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 UTRILLO PL
PALM COAST FL
32164-5901
US

IV. Provider business mailing address

24 UTRILLO PL
PALM COAST FL
32164-5901
US

V. Phone/Fax

Practice location:
  • Phone: 386-347-9873
  • Fax:
Mailing address:
  • Phone: 386-347-9873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11046877
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: