Individual
AMANDA KRISTEN DOMINGUEZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
11005 NORRIS AVE # 43, PACOIMA, CA 91331-2501
(818) 480-1144
Mailing address
11005 NORRIS AVE # 43, PACOIMA, CA 91331-2501
(818) 480-1144
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2013
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
XEH910101639
BLUE SHIELD
—
Enumeration date
06/22/2021
Last updated
06/22/2021
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