Provider Demographics
NPI:1598277220
Name:WOLF, DEIRDRE RAQUEL (AGNP)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:RAQUEL
Last Name:WOLF
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E CHEYENNE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3720
Mailing Address - Country:US
Mailing Address - Phone:719-396-3003
Mailing Address - Fax:719-396-3003
Practice Address - Street 1:218 E CHEYENNE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3720
Practice Address - Country:US
Practice Address - Phone:850-879-1801
Practice Address - Fax:719-396-3003
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN0993468-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner