Provider Demographics
NPI:1932737608
Name:ODELL WILSON, AMY SUE (LIC ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:ODELL WILSON
Suffix:
Gender:F
Credentials:LIC ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 GARLAND WAY
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-2050
Mailing Address - Country:US
Mailing Address - Phone:603-289-1989
Mailing Address - Fax:
Practice Address - Street 1:78 CONCORD STREET
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458
Practice Address - Country:US
Practice Address - Phone:603-924-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH292171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist