=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639046402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIESHIEA D WOLF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2025
-----------------------------------------------------
Last Update Date | 10/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 SCARLETT RD
-----------------------------------------------------
City | CARMEL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93924-9437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-884-1000
-----------------------------------------------------
Fax | 831-884-1014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 SCARLETT RD
-----------------------------------------------------
City | CARMEL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93924-9437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-884-1000
-----------------------------------------------------
Fax | 831-884-1014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 545923
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------