Healthcare Provider Details

I. General information

NPI: 1558577569
Provider Name (Legal Business Name): NANCY WOLF FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY LOOMAN FNP

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 HEMLOCK ST SUITE 2D
BROOKINGS OR
97415-9424
US

IV. Provider business mailing address

94220 4TH ST
GOLD BEACH OR
97444-7756
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2094
  • Fax: 541-469-6867
Mailing address:
  • Phone: 541-247-3000
  • Fax: 541-247-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number081001426
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200650003NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: