Provider Demographics
NPI:1033296033
Name:WOLF, AMY AYLA (LAC)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:AYLA
Last Name:WOLF
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:KRISTINE
Other - Last Name:MOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:461 NE GREENWOOD AVE.
Mailing Address - Street 2:STE A
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4607
Mailing Address - Country:US
Mailing Address - Phone:541-233-9352
Mailing Address - Fax:971-256-8865
Practice Address - Street 1:461 NE GREENWOOD AVE.
Practice Address - Street 2:STE A
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4607
Practice Address - Country:US
Practice Address - Phone:541-233-9352
Practice Address - Fax:971-256-8865
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3734171100000X
ORAC01012171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist