Provider Demographics
NPI:1730965666
Name:DOMINGUEZ, SHALYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHALYNN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:SHALYNN
Other - Middle Name:GWEN
Other - Last Name:LORING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WATHENA
Mailing Address - State:KS
Mailing Address - Zip Code:66090-4114
Mailing Address - Country:US
Mailing Address - Phone:785-243-0054
Mailing Address - Fax:
Practice Address - Street 1:4119 NW BARRY RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1100
Practice Address - Country:US
Practice Address - Phone:816-452-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS225200000X
MO225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant