Basic Information
| Provider Information | |||||||||
| NPI: | 1265197040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | MARI | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419631883 | ||||||||
| FaxNumber: | 5419622560 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 FOURTH ST. | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633138 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2021 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 202111998NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.