Provider Demographics
NPI:1124893151
Name:WILSON, DOMONIQUE S (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 N CRAIG ST STE B
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-1569
Mailing Address - Country:US
Mailing Address - Phone:610-892-3800
Mailing Address - Fax:
Practice Address - Street 1:230 N CRAIG ST STE B
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-1569
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029678363LP0808X
OHAPRNCNP0035421363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health