Healthcare Provider Details

I. General information

NPI: 1467309542
Provider Name (Legal Business Name): SANDRA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 BLUE GENTIAN RD
SAINT PAUL MN
55121-1564
US

IV. Provider business mailing address

643 PARKSIDE CT
SAINT PAUL MN
55123-2197
US

V. Phone/Fax

Practice location:
  • Phone: 763-215-0368
  • Fax:
Mailing address:
  • Phone: 763-215-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: