Provider Demographics
NPI:1629853650
Name:WILSON, AMY NICOLE (MED, MS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, MS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:12 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:NINNEKAH
Mailing Address - State:OK
Mailing Address - Zip Code:73067-9625
Mailing Address - Country:US
Mailing Address - Phone:405-278-1694
Mailing Address - Fax:
Practice Address - Street 1:117 S 7TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-3301
Practice Address - Country:US
Practice Address - Phone:405-222-4786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK318398171M00000X
OKLPCCANDIDATE11968101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator