Healthcare Provider Details

I. General information

NPI: 1639046402
Provider Name (Legal Business Name): TIESHIEA D WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2025
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SCARLETT RD
CARMEL VALLEY CA
93924-9437
US

IV. Provider business mailing address

1 SCARLETT RD
CARMEL VALLEY CA
93924-9437
US

V. Phone/Fax

Practice location:
  • Phone: 831-884-1000
  • Fax: 831-884-1014
Mailing address:
  • Phone: 831-884-1000
  • Fax: 831-884-1014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number545923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: