Provider Demographics
NPI:1225360977
Name:WOLFRAM, ROXANNE (FNP)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:WOLFRAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NILES AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-983-3380
Mailing Address - Fax:269-983-0353
Practice Address - Street 1:2500 NILES AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-983-3380
Practice Address - Fax:269-983-0353
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115108A163W00000X
MI4704168735163W00000X, 363L00000X
IN71000517A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily