Provider Demographics
NPI:1497730238
Name:WOLF, MELODIE A (ARNP)
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:A
Last Name:WOLF
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4562 E HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8831
Mailing Address - Country:US
Mailing Address - Phone:850-897-8550
Mailing Address - Fax:
Practice Address - Street 1:4562 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8831
Practice Address - Country:US
Practice Address - Phone:850-897-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP976242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY016HOtherBLUE CROSS
FL305182000Medicaid
P77726Medicare UPIN