Healthcare Provider Details

I. General information

NPI: 1598454712
Provider Name (Legal Business Name): MOLLIE WOLFE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8823 SAN JOSE BLVD
JACKSONVILLE FL
32217-4287
US

IV. Provider business mailing address

4758 CUMBERLAND STATION CT
JACKSONVILLE FL
32257-5111
US

V. Phone/Fax

Practice location:
  • Phone: 904-404-7044
  • Fax: 904-329-2303
Mailing address:
  • Phone: 912-614-6465
  • Fax: 904-329-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117374
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: