Provider Demographics
NPI:1326724378
Name:WILD, AMBER FAE (BFA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:FAE
Last Name:WILD
Suffix:
Gender:F
Credentials:BFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BURGOYNE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057-2000
Mailing Address - Country:US
Mailing Address - Phone:860-906-4274
Mailing Address - Fax:
Practice Address - Street 1:280 MAIN ST # C
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06057-2748
Practice Address - Country:US
Practice Address - Phone:860-251-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTTAT.000490246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other