MEDICARE: SAMIRA DOMINGO RN, CLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	846436	CA

General Provider Information

NPI Number	:	1922963917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMIRA DOMINGO RN, CLC

Provider Business Mailing Address
First Line	:	91-1101 KAIMALIE ST APT 2T2
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	91-1101 KAIMALIE ST APT 2T2
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5052
Country	:	US
Telephone Number	:	916-743-1005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2025
Last Update Date	:	12/22/2025

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