Provider Demographics
NPI:1659488252
Name:WOLF, CARRIE BETH (CNM)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:BETH
Last Name:WOLF
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:BETH
Other - Last Name:HRUBABLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:5520 PARK AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-374-1018
Mailing Address - Fax:203-396-0699
Practice Address - Street 1:5520 PARK AVE STE WP2-700
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-374-1018
Practice Address - Fax:203-396-0699
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000197367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004208444Medicaid