Provider Demographics
NPI:1538564109
Name:WOLFE SEPULVEDA, LARA LYNN (NP)
Entity type:Individual
Prefix:MS
First Name:LARA
Middle Name:LYNN
Last Name:WOLFE SEPULVEDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:LYNN
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2914
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:3864 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4703
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-995-8503
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7265363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ974851Medicaid
AZZ174316Medicare PIN