1730965666 NPI number — MRS. SHALYNN DOMINGUEZ PTA

Table of content: DR. LISA S. JONES MD (NPI 1841493376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730965666 NPI number — MRS. SHALYNN DOMINGUEZ PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
SHALYNN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LORING
Provider Other First Name:
SHALYNN
Provider Other Middle Name:
GWEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730965666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 SHERMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATHENA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66090-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-243-0054
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4119 NW BARRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64154-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-452-4488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)