Healthcare Provider Details

I. General information

NPI: 1700752599
Provider Name (Legal Business Name): MARLEVY DOMINGUEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672 SW PRIMA VISTA BLVD STE 102
PORT ST LUCIE FL
34983-1820
US

IV. Provider business mailing address

PO BOX 4189
DEERFIELD BEACH FL
33442-4189
US

V. Phone/Fax

Practice location:
  • Phone: 772-905-2560
  • Fax: 772-336-8341
Mailing address:
  • Phone: 772-905-2560
  • Fax: 772-336-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11042914
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: