Provider Demographics
NPI:1558912477
Name:WOLFF, SUSAN GAIL (PMH-NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:WOLFF
Suffix:
Gender:F
Credentials:PMH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 GLORY VISTA TER
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8997
Mailing Address - Country:US
Mailing Address - Phone:307-690-4368
Mailing Address - Fax:
Practice Address - Street 1:745 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-332-2941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY44657363LP0808X
ID67729363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health