Provider Demographics
NPI:1568297265
Name:DOMINGUEZ, AMANDA LYNNE (RN,CWOCN)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNNE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:RN,CWOCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5164 STRAUB RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6952
Mailing Address - Country:US
Mailing Address - Phone:979-676-2154
Mailing Address - Fax:
Practice Address - Street 1:5164 STRAUB RD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6952
Practice Address - Country:US
Practice Address - Phone:979-676-2154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX791866163WC2100X, 163WE0900X, 163WW0000X, 163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care