Provider Demographics
NPI:1790849453
Name:WIELKOPOLAN, AMY R (LMBT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:R
Last Name:WIELKOPOLAN
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 CREPE MYRTLE CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-4307
Mailing Address - Country:US
Mailing Address - Phone:843-504-2905
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:4370 CREPE MYRTLE CT UNIT A
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-4307
Practice Address - Country:US
Practice Address - Phone:843-504-2905
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3663302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization