=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295405371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER BROOKE DOMEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2021
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 W 7TH ST
-----------------------------------------------------
City | SHINER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77984-5873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-239-5015
-----------------------------------------------------
Fax | 361-239-5014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 587
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78629-0587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-239-5015
-----------------------------------------------------
Fax | 361-239-5014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1052400
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1052400
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------