Basic Information
| Provider Information | |||||||||
| NPI: | 1558577569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
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| OtherLastName: | LOOMAN | ||||||||
| OtherFirstName: | NANCY | ||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 94220 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412473000 | ||||||||
| FaxNumber: | 5412473101 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 HEMLOCK ST | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974159424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414122094 | ||||||||
| FaxNumber: | 5414696867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 081001426 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP0808X | 200650003NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1487696985 | 01 | OR | CURRY HEALTH DISTRICT | OTHER | 292124 | 05 | OR | MEDICAID |