Provider Demographics
NPI:1245597236
Name:WILCOX, AMY SUE
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:SUE
Last Name:WILCOX
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 1:316 1/2 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1811
Mailing Address - Country:US
Mailing Address - Phone:419-889-9464
Mailing Address - Fax:
Practice Address - Street 1:316 1/2 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1811
Practice Address - Country:US
Practice Address - Phone:419-889-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0062118Medicaid