Provider Demographics
NPI:1225654304
Name:WICKHAM, AMY LEE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6992 OPTIMARA DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-7766
Mailing Address - Country:US
Mailing Address - Phone:614-561-7577
Mailing Address - Fax:
Practice Address - Street 1:14196 NATIONAL RD SW
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:OH
Practice Address - Zip Code:43068-3365
Practice Address - Country:US
Practice Address - Phone:740-927-6782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04376225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04376OtherLICENSE NUMBER