Provider Demographics
NPI:1194251272
Name:DOMINGO, CARLO (AGNP-C)
Entity type:Individual
Prefix:
First Name:CARLO
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 N DEER POINT DR.
Mailing Address - Street 2:STE 1002
Mailing Address - City:HAINESVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3814
Mailing Address - Country:US
Mailing Address - Phone:847-946-0198
Mailing Address - Fax:
Practice Address - Street 1:4 N DEER POINT DR
Practice Address - Street 2:STE 1002
Practice Address - City:HAINESVILLE
Practice Address - State:IL
Practice Address - Zip Code:60030-3814
Practice Address - Country:US
Practice Address - Phone:847-946-0198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019378363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health