Healthcare Provider Details

I. General information

NPI: 1619357381
Provider Name (Legal Business Name): MRS. MARLO WOLFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 COUNTY ROAD 59
PINE APPLE AL
36768-3525
US

IV. Provider business mailing address

PO BOX 2213 713 J L CHESTNUT BLVD
SELMA AL
36702-2213
US

V. Phone/Fax

Practice location:
  • Phone: 251-746-2197
  • Fax: 251-746-2467
Mailing address:
  • Phone: 334-874-7428
  • Fax: 334-874-7435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-087171
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-087171
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: