Provider Demographics
NPI:1043425655
Name:WEDDLE, AMY NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:WEDDLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2883
Mailing Address - Country:US
Mailing Address - Phone:503-545-1066
Mailing Address - Fax:
Practice Address - Street 1:4425 SW CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4260
Practice Address - Country:US
Practice Address - Phone:503-225-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist