Basic Information
| Provider Information | |||||||||
| NPI: | 1619520764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | MICAELA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1103 NE PINE HILL TER | ||||||||
| Address2: | |||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349573786 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 SE HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2019 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | APRN11003301 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | 363L00000X | 11003301 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.