Healthcare Provider Details

I. General information

NPI: 1427668151
Provider Name (Legal Business Name): DOMINIQUE HOLMES PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 07/19/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S. 376 SUMMIT AVE COURT D
OAKBROOK TERRACE IL
60181
US

IV. Provider business mailing address

7758 S PEORIA ST APT 2
CHICAGO IL
60620-2824
US

V. Phone/Fax

Practice location:
  • Phone: 773-238-2828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209024564
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041460162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: