Provider Demographics
NPI:1194388009
Name:DOMANGUE, MARILYN (FNP-C)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DOMANGUE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-1462
Mailing Address - Country:US
Mailing Address - Phone:682-554-7071
Mailing Address - Fax:
Practice Address - Street 1:601 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1462
Practice Address - Country:US
Practice Address - Phone:682-554-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-09-05
Deactivation Date:2024-08-29
Deactivation Code:
Reactivation Date:2024-09-04
Provider Licenses
StateLicense IDTaxonomies
TX964560163W00000X
TX1173391363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse