Healthcare Provider Details

I. General information

NPI: 1649570250
Provider Name (Legal Business Name): SARA LYNNE WOLFSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 S 110TH ST
OMAHA NE
68144-3115
US

IV. Provider business mailing address

2104 S 110TH ST
OMAHA NE
68144-3115
US

V. Phone/Fax

Practice location:
  • Phone: 402-201-1977
  • Fax:
Mailing address:
  • Phone: 402-201-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberJ-126582
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: