Provider Demographics
NPI:1942337696
Name:WILLCOCKSON, AMY MICHELLE (DC)
Entity Type:Individual
Prefix:DR
First Name:AMY MICHELLE
Middle Name:
Last Name:WILLCOCKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W WAYZATA BLVD
Mailing Address - Street 2:P.O. BOX 181
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9491
Mailing Address - Country:US
Mailing Address - Phone:952-476-2260
Mailing Address - Fax:952-476-4457
Practice Address - Street 1:1850 W WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-9491
Practice Address - Country:US
Practice Address - Phone:952-476-2260
Practice Address - Fax:952-476-4457
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3845111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation