Provider Demographics
NPI:1063932184
Name:DOMINGO, MARIANE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARIANE
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARIANE
Other - Middle Name:
Other - Last Name:MANALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:847-390-4757
Practice Address - Street 1:3134 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4414
Practice Address - Country:US
Practice Address - Phone:773-766-1949
Practice Address - Fax:773-766-4908
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily