Provider Demographics
NPI:1891155727
Name:WYLDE, AMY (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WYLDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7977 170TH AVE NE APT B419
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-4078
Mailing Address - Country:US
Mailing Address - Phone:360-296-9933
Mailing Address - Fax:
Practice Address - Street 1:7977 170TH AVE NE APT B419
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4078
Practice Address - Country:US
Practice Address - Phone:360-296-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60629004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist