Provider Demographics
NPI:1568715027
Name:WOLF-CARRIZO, ANA MARIA
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA
Last Name:WOLF-CARRIZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-1931
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:545 ROWLETT RD
Practice Address - Street 2:SUITE A OR B
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-3700
Practice Address - Country:US
Practice Address - Phone:972-303-7021
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82507133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid