Basic Information
| Provider Information | |||||||||
| NPI: | 1497022727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | KRYSTAL | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4109 HIGHWAY 98 W | ||||||||
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| City: | SUMMIT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396669132 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 909 S LAKESIDE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338031031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636885521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA14657 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.