Provider Demographics
NPI:1639798648
Name:WOLF, LARISSA CHRISTINA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:CHRISTINA
Last Name:WOLF
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 1:975 E 3RD ST., HOSPITAL BOX 112
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN0000067695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program