Provider Demographics
NPI:1710691837
Name:WIMMER, AMY NICOLE (DPT, PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:WIMMER
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-457-4461
Mailing Address - Fax:920-459-1483
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1483
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100230198Medicaid