Provider Demographics
NPI:1730965195
Name:WOLFE, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 DALE CT
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1717
Mailing Address - Country:US
Mailing Address - Phone:516-650-2853
Mailing Address - Fax:
Practice Address - Street 1:835 DEMOTT AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510
Practice Address - Country:US
Practice Address - Phone:516-667-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1269641181390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program