MEDICARE: MRS. DOMONIQUE N WILSON FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	28261922A	IN

General Provider Information

NPI Number	:	1942163654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOMONIQUE N WILSON FNP-BC

Provider Business Mailing Address
First Line	:	10549 ONTARIO DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9371
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10549 ONTARIO DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9371
Country	:	US
Telephone Number	:	928-278-0027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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