Healthcare Provider Details

I. General information

NPI: 1386620896
Provider Name (Legal Business Name): KATERINA STURSOVA-WOLFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8910 VERNON RD
LAKE STEVENS WA
98258-2400
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-397-1702
  • Fax: 425-335-5145
Mailing address:
  • Phone: 425-397-1702
  • Fax: 425-335-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60451748
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number216086
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: