Provider Demographics
NPI:1578152526
Name:WOLF, LISA (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10490 CLAYMORE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-7330
Mailing Address - Country:US
Mailing Address - Phone:205-753-0443
Mailing Address - Fax:
Practice Address - Street 1:17222 HOSPITAL BLVD STE 120
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8906
Practice Address - Country:US
Practice Address - Phone:205-753-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011057363LP0808X
WAAP61498540363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1134992191OtherNPPES
1578152526OtherNPPES