=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336694025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRISTY WOLFE ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2016
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3197 CARRABASSETT DR
-----------------------------------------------------
City | CARRABASSETT VALLEY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04947-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-237-4494
-----------------------------------------------------
Fax | 207-237-4041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3197 CARRABASSETT DR
-----------------------------------------------------
City | CARRABASSETT VALLEY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04947-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-237-4494
-----------------------------------------------------
Fax | 207-237-4041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT524
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------