Provider Demographics
NPI:1225270333
Name:WACHTMAN, AMY LEE (CO)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LEE
Last Name:WACHTMAN
Suffix:
Gender:F
Credentials:CO
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:LEE
Other - Last Name:CALLAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CO
Mailing Address - Street 1:2116 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4614
Mailing Address - Country:US
Mailing Address - Phone:918-742-6464
Mailing Address - Fax:918-742-9933
Practice Address - Street 1:2116 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4614
Practice Address - Country:US
Practice Address - Phone:918-742-6464
Practice Address - Fax:918-742-9933
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKALO49222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKALO49OtherBOARD OF MEDICAL LICENSURE & SUPERVISION STATE OF OKLAHOMA
CO003335OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS & PROSTHETICS