Provider Demographics
NPI:1700759966
Name:WILSON, DOMINQUE
Entity type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8444 N 90TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4437
Mailing Address - Country:US
Mailing Address - Phone:602-248-8886
Mailing Address - Fax:602-248-8999
Practice Address - Street 1:25639 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-4817
Practice Address - Country:US
Practice Address - Phone:313-277-3293
Practice Address - Fax:313-277-0917
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704360018163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse