Provider Demographics
NPI:1083431498
Name:DOMINGUEZ, MIRANDA KAYE (LVN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KAYE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7909 FREDERICKSBURG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3403
Mailing Address - Country:US
Mailing Address - Phone:210-437-0884
Mailing Address - Fax:
Practice Address - Street 1:7909 FREDERICKSBURG RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3403
Practice Address - Country:US
Practice Address - Phone:210-437-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX349487164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse