=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013560796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKAELA WOLF AGACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 07/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COMMUNITY DR
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-562-4834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 MARINA POINTE DR
-----------------------------------------------------
City | EAST ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11518-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-255-6645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 431547
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------