Basic Information
| Provider Information | |||||||||
| NPI: | 1063089803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | CELIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOLANO | ||||||||
| OtherFirstName: | LARISSA | ||||||||
| OtherMiddleName: | CELIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 40700 CALIFORNIA OAKS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518945072 | ||||||||
| FaxNumber: | 9518947324 | ||||||||
| Practice Location | |||||||||
| Address1: | 40700 CALIFORNIA OAKS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518945072 | ||||||||
| FaxNumber: | 9518947324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2021 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 698464 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.