Provider Demographics
NPI:1164471694
Name:WOLFF, PHYLLIS JOAN (NP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:JOAN
Last Name:WOLFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 N OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2649
Mailing Address - Country:US
Mailing Address - Phone:631-758-5858
Mailing Address - Fax:
Practice Address - Street 1:1723 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2649
Practice Address - Country:US
Practice Address - Phone:631-758-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301342363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP12375Medicare UPIN