Provider Demographics
NPI:1699368829
Name:WOLF, MICHELLE RENE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE
Last Name:WOLF
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENE
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1890 HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-5710
Mailing Address - Country:US
Mailing Address - Phone:321-863-7630
Mailing Address - Fax:
Practice Address - Street 1:4311 NORFOLK PKWY STE 114
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8617
Practice Address - Country:US
Practice Address - Phone:321-291-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004051363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner