Individual
CANDICE LEANN DOMINGUEZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
40936 E COUNTY ROAD 1230, KEOTA, OK 74941-6439
(918) 471-8936
Mailing address
40936 E COUNTY ROAD 1230, KEOTA, OK 74941-6439
(918) 471-8936
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
1-14-12
OK
Other
Enumeration date
10/29/2012
Last updated
10/29/2012
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