Provider Demographics
NPI:1295019909
Name:WILSON, DOMINIQUE RENEE (DNP, PMHNP, FNP)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DNP, PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SE SPOKANE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6487
Mailing Address - Country:US
Mailing Address - Phone:855-704-2004
Mailing Address - Fax:503-386-3366
Practice Address - Street 1:205 SE SPOKANE ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6487
Practice Address - Country:US
Practice Address - Phone:855-704-2004
Practice Address - Fax:503-386-3366
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202100794NPPP363LF0000X
TXAP119115363LF0000X, 363LP0808X
WAAP61131624363LP0808X
OR202100794NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily