Healthcare Provider Details

I. General information

NPI: 1316152010
Provider Name (Legal Business Name): WOLFE FAMILY MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E WALNUT ST
CHARLESTON MS
38921
US

IV. Provider business mailing address

PO BOX 69 203 EAST WALNUT STREET
CHARLESTON MS
38921-0069
US

V. Phone/Fax

Practice location:
  • Phone: 662-647-0900
  • Fax: 662-647-0938
Mailing address:
  • Phone: 662-647-0900
  • Fax: 662-647-0938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. CARLENE M WOLFE
Title or Position: NURSE PRACTITIONER OWNER
Credential: CFNP
Phone: 662-647-0900