Most Relevant Information
Provider Data
| NPI Number: | 1003506007 |
| Provider Name: | ELIZABETH DIANE DOMINGUEZ |
| Entity Type: | Individual |
| Taxonomy Code: | 390200000X |
| Specialty: | Student in an Organized Health Care Education/Training Program |
| License Number: |
Most Important Dates
| Enumeration Date: | 05/11/2023 |
| Last Updated: | 05/11/2023 |
Provider Practice Location
9200 W WISCONSIN AVE
WAUWATOSA
WI
532263522
Practice Location Phone/Fax
| Phone: | 4148050505 |
| Fax: |
Provider Mailing Location
9200 W WISCONSIN AVE
WAUWATOSA
WI
532263522
Provider Mailing Phone/Fax
| Phone: | |
| Fax: |