Provider Demographics
NPI:1275745010
Name:WILSON, AMY CAROLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:CAROLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S ROY ST
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-2992
Mailing Address - Country:US
Mailing Address - Phone:870-946-3497
Mailing Address - Fax:
Practice Address - Street 1:601 S UNION ST
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:AR
Practice Address - Zip Code:72042-2727
Practice Address - Country:US
Practice Address - Phone:870-946-1606
Practice Address - Fax:870-946-2937
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1463225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant