Provider Demographics
NPI:1154660058
Name:WOLFE, KEISHA DALE (DO)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:DALE
Last Name:WOLFE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:D
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:711 DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301
Mailing Address - Country:US
Mailing Address - Phone:931-261-6098
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015
Practice Address - Country:US
Practice Address - Phone:202-476-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102203917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program