Healthcare Provider Details

I. General information

NPI: 1730540097
Provider Name (Legal Business Name): ASHLEY DOMETRIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 22ND PL
LUBBOCK TX
79410-1119
US

IV. Provider business mailing address

3420 22ND PL
LUBBOCK TX
79410-1314
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-0030
  • Fax: 806-725-0015
Mailing address:
  • Phone: 806-725-5844
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP130554
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: