Healthcare Provider Details

I. General information

NPI: 1093188724
Provider Name (Legal Business Name): JANET E DOMINGUEZ C-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GEORGIA ST NE
ALBUQUERQUE NM
87110-2620
US

IV. Provider business mailing address

P.O. BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-1273
  • Fax: 505-396-4007
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02792
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: