=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346765823
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. DEVON WOLFKIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2017
-----------------------------------------------------
Last Update Date | 07/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3431 BROADWAY ST STE A8
-----------------------------------------------------
City | AMERICAN CANYON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94503-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-264-0146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 257 CAVEDALE RD
-----------------------------------------------------
City | SONOMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95476-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-645-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F342111-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95007867
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------