| NPI | 1538784004 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DOMINIQUE RENEE WILSON Owner And Provider 855-704-2004 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family |
| Enumeration Date | 2020-06-10 |
| Last Update Date | 2023-08-09 |