Provider Demographics
NPI:1861262750
Name:WILKIE, AMANDA (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILKIE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1376
Mailing Address - Country:US
Mailing Address - Phone:618-339-3614
Mailing Address - Fax:
Practice Address - Street 1:203 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1810
Practice Address - Country:US
Practice Address - Phone:618-339-3614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021470225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist