Provider Demographics
NPI:1063089803
Name:DOMINGUEZ, LARISSA CELIA (LVN)
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:CELIA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:CELIA
Other - Last Name:MOLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40700 CALIFORNIA OAKS RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5789
Mailing Address - Country:US
Mailing Address - Phone:951-894-5072
Mailing Address - Fax:951-894-7324
Practice Address - Street 1:40700 CALIFORNIA OAKS RD STE 202
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5789
Practice Address - Country:US
Practice Address - Phone:951-894-5072
Practice Address - Fax:951-894-7324
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA698464164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse