Provider Demographics
NPI:1124417456
Name:WOLF, MEGAN (MS, RD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 38TH ST
Mailing Address - Street 2:APT 3A
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4106
Mailing Address - Country:US
Mailing Address - Phone:917-992-3192
Mailing Address - Fax:
Practice Address - Street 1:200 E 78TH ST
Practice Address - Street 2:STE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-2010
Practice Address - Country:US
Practice Address - Phone:917-992-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1097772133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered