=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477945954
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDRA LOUISA WOLFE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2015
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 MONTGOMERY ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-702-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 99335
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76199-0335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-702-6111
-----------------------------------------------------
Fax | 817-735-0111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 798527
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP127529
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------