Provider Demographics
NPI:1073690376
Name:WOLFE, SUSAN ADELE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ADELE
Last Name:WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:ADELE
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:804 EAGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-9032
Mailing Address - Country:US
Mailing Address - Phone:765-481-1219
Mailing Address - Fax:
Practice Address - Street 1:804 EAGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-9032
Practice Address - Country:US
Practice Address - Phone:317-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000430A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
M400029155OtherMEDICARE