Provider Demographics
NPI:1881956613
Name:WILSON, AIMY MARIE
Entity type:Individual
Prefix:MRS
First Name:AIMY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AIMY
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED NAIL TECH
Mailing Address - Street 1:1266 SW 50TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-1310
Mailing Address - Country:US
Mailing Address - Phone:541-848-1445
Mailing Address - Fax:
Practice Address - Street 1:1266 SW 50TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-1310
Practice Address - Country:US
Practice Address - Phone:541-848-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCOS-NT-10135071211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric