Provider Demographics
NPI:1699317123
Name:DOMINGUEZ, SOFIA MAITE
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:MAITE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3659 S MIAMI AVE
Mailing Address - Street 2:STE 3005
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4225
Mailing Address - Country:US
Mailing Address - Phone:305-860-6260
Mailing Address - Fax:305-860-6590
Practice Address - Street 1:1055 BELLA VISTA AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33156-6451
Practice Address - Country:US
Practice Address - Phone:786-239-3527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily