Provider Demographics
NPI:1649732009
Name:WILDER, AMY L (HAS, BC-HIS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:WILDER
Suffix:
Gender:F
Credentials:HAS, BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10929 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6417
Mailing Address - Country:US
Mailing Address - Phone:772-337-2526
Mailing Address - Fax:772-337-2589
Practice Address - Street 1:10929 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6417
Practice Address - Country:US
Practice Address - Phone:772-337-2526
Practice Address - Fax:772-337-2589
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5334237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty