Provider Demographics
NPI:1174009898
Name:WOLFF, GREGORY LEE (MSN/BSN, RN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:WOLFF
Suffix:
Gender:M
Credentials:MSN/BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 DOGWOOD ST NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-1336
Mailing Address - Country:US
Mailing Address - Phone:253-332-4848
Mailing Address - Fax:
Practice Address - Street 1:9720 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4456
Practice Address - Country:US
Practice Address - Phone:253-503-3666
Practice Address - Fax:253-503-1633
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60280098163W00000X, 163WA0400X, 163WC0400X, 163WP0808X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60280098OtherRN LICENSE