Healthcare Provider Details

I. General information

NPI: 1437674793
Provider Name (Legal Business Name): MONICA FAYE WOLF PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONICA FAYE MILLS PA

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 BAPTIST BLVD STE 401
COLUMBUS MS
39705
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 662-244-2288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00434
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: