Provider Demographics
NPI:1033125802
Name:WOLFE, DANA LARA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LARA
Last Name:WOLFE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23296 STOFLET LN
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-5408
Mailing Address - Country:US
Mailing Address - Phone:843-250-1895
Mailing Address - Fax:
Practice Address - Street 1:16525 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1403
Practice Address - Country:US
Practice Address - Phone:734-250-9529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2997363LF0000X
MI4704154939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1747Medicaid
SCP00906569OtherRAILROAD MEDICARE PTAN
MI4704154939OtherLICENSE #
SC2997OtherLICENSE #
SCNP1747Medicaid