Provider Demographics
NPI:1396477030
Name:DOMINGUEZ, THERESA ELIZABETH (RN IBCLC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ELIZABETH
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:THERES
Other - Middle Name:ELIZABETH
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1621 LAKEVILLE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2694
Mailing Address - Country:US
Mailing Address - Phone:281-305-0411
Mailing Address - Fax:
Practice Address - Street 1:12777 JONES RD STE 440
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4600
Practice Address - Country:US
Practice Address - Phone:281-305-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX781135163W00000X
TXL-166288163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse