Healthcare Provider Details

I. General information

NPI: 1265197040
Provider Name (Legal Business Name): MARI PATRICIA DOMINGUEZ NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 COVE AVE
LA GRANDE OR
97850-3906
US

IV. Provider business mailing address

2301 COVE AVE
LA GRANDE OR
97850-3906
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-8800
  • Fax: 541-963-5272
Mailing address:
  • Phone: 541-962-8800
  • Fax: 541-963-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202111998NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: