Healthcare Provider Details

I. General information

NPI: 1356543367
Provider Name (Legal Business Name): VANESSA AUDREY WOLFMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE CHILDREN'S HOSPITAL BOSTON DEPARTMENT OF MEDICINE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE CHILDREN'S HOSPITAL BOSTON DEPARTMENT OF MEDICINE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7793
  • Fax: 617-739-0330
Mailing address:
  • Phone: 617-355-7793
  • Fax: 617-739-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP01149
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number245626
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: