Healthcare Provider Details

I. General information

NPI: 1174992671
Provider Name (Legal Business Name): DAWN WULF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

IV. Provider business mailing address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

V. Phone/Fax

Practice location:
  • Phone: 575-914-0055
  • Fax:
Mailing address:
  • Phone: 575-914-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02765
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: