Provider Demographics
NPI:1518567874
Name:WILSON, DOMINIQUE (CNM)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N ESTRELLA PKWY STE A107
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9276
Mailing Address - Country:US
Mailing Address - Phone:623-263-0105
Mailing Address - Fax:623-292-8825
Practice Address - Street 1:1170 N ESTRELLA PKWY STE A107
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9276
Practice Address - Country:US
Practice Address - Phone:623-263-0105
Practice Address - Fax:623-292-8825
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
AZ250020176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife