Provider Demographics
NPI:1033627187
Name:WOLF, KALLI M (APRN, CMW)
Entity Type:Individual
Prefix:
First Name:KALLI
Middle Name:M
Last Name:WOLF
Suffix:
Gender:F
Credentials:APRN, CMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 BANBURY LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-3401
Mailing Address - Country:US
Mailing Address - Phone:405-203-5382
Mailing Address - Fax:
Practice Address - Street 1:2104 BANBURY LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-3401
Practice Address - Country:US
Practice Address - Phone:405-203-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CNM04688367A00000X
OK121796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200776420AMedicaid