Provider Demographics
NPI:1851045199
Name:WILSON, AMBER JENAI
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:JENAI
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29293 DERECK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3728
Mailing Address - Country:US
Mailing Address - Phone:248-802-0651
Mailing Address - Fax:
Practice Address - Street 1:29293 DERECK DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3728
Practice Address - Country:US
Practice Address - Phone:248-802-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier