Healthcare Provider Details

I. General information

NPI: 1942163654
Provider Name (Legal Business Name): DOMONIQUE N WILSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10549 ONTARIO DR
CROWN POINT IN
46307-9371
US

IV. Provider business mailing address

10549 ONTARIO DR
CROWN POINT IN
46307-9371
US

V. Phone/Fax

Practice location:
  • Phone: 928-278-0027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28261922A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: