Provider Demographics
NPI:1114904265
Name:WOLF, DEBRA JEAN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:JEAN
Last Name:WOLF
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 COURT ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1077
Mailing Address - Country:US
Mailing Address - Phone:606-723-2167
Mailing Address - Fax:606-723-2112
Practice Address - Street 1:275 COURT ST
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1077
Practice Address - Country:US
Practice Address - Phone:606-723-2167
Practice Address - Fax:606-723-2112
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 1030153 24198207R00000X
KY3002419363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY183919OtherRIVERBEND GOVERNMENT
KY35001643Medicaid
KY78005014Medicaid
KYK138990Medicare PIN
S36915Medicare UPIN
KY0726102Medicare PIN