Provider Demographics
NPI:1891180717
Name:WICKSTROM, AMY
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:WICKSTROM
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 1:3401 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-4102
Mailing Address - Country:US
Mailing Address - Phone:517-243-3996
Mailing Address - Fax:
Practice Address - Street 1:301 LONG RAPIDS RD
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1317
Practice Address - Country:US
Practice Address - Phone:989-356-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003335225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant