Healthcare Provider Details

I. General information

NPI: 1619139359
Provider Name (Legal Business Name): MARY LOU WULF CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY LOU ZIRKELBACH

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N SENATE BLVD RM AG 001
INDIANAPOLIS IN
46202-1239
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-3886
  • Fax: 317-962-8652
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number70000209
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number70000209A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: