Healthcare Provider Details

I. General information

NPI: 1245597236
Provider Name (Legal Business Name): MS. AMY SUE WILCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 1/2 LAUREL AVE
PORT CLINTON OH
43452-1811
US

IV. Provider business mailing address

316 1/2 LAUREL AVE
PORT CLINTON OH
43452-1811
US

V. Phone/Fax

Practice location:
  • Phone: 419-889-9464
  • Fax:
Mailing address:
  • Phone: 419-889-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: