Provider Demographics
NPI:1538523865
Name:DOMINGUEZ, KRISTINA ANGELICA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANGELICA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 SE JAMAICA DR
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3989
Mailing Address - Country:US
Mailing Address - Phone:479-381-4366
Mailing Address - Fax:
Practice Address - Street 1:5350 S WESTERN AVE
Practice Address - Street 2:525
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-4520
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4507235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist