Healthcare Provider Details

I. General information

NPI: 1184163149
Provider Name (Legal Business Name): LYNAE WOLF APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 05/18/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 170-123-4200
  • Fax:
Mailing address:
  • Phone: 701-234-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR37765
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: