Basic Information
| Provider Information | |||||||||
| NPI: | 1871083683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFRUM | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SKELTON | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24116 MEADOWBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480353008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074859541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17900 23 MILE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480441161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5868689200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2018 | ||||||||
| LastUpdateDate: | 04/19/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 4704289427 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 4704289427 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.