Provider Demographics
NPI:1154513471
Name:WILSON, AMY JO (LPN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 S DEWITT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-8200
Mailing Address - Country:US
Mailing Address - Phone:989-224-2495
Mailing Address - Fax:
Practice Address - Street 1:4207 S DEWITT RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-8200
Practice Address - Country:US
Practice Address - Phone:989-224-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703050554164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse