Healthcare Provider Details

I. General information

NPI: 1407325731
Provider Name (Legal Business Name): TABATHA DOMINGUEZ NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 AVENUE E
HONDO TX
78861-3525
US

IV. Provider business mailing address

PO BOX 752
HONDO TX
78861-0752
US

V. Phone/Fax

Practice location:
  • Phone: 830-426-7444
  • Fax:
Mailing address:
  • Phone: 830-931-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP139722
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: