Provider Demographics
NPI:1639624810
Name:WILLIAMS, DOMIQUE (MS, WHNP)
Entity Type:Individual
Prefix:
First Name:DOMIQUE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 STEVENS AVENUE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-665-2229
Mailing Address - Fax:
Practice Address - Street 1:105 STEVENS AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2686
Practice Address - Country:US
Practice Address - Phone:914-665-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607735-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner