Provider Demographics
NPI:1730128463
Name:WULF, KATHY JOLENE (NP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JOLENE
Last Name:WULF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51265 221ST ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534
Mailing Address - Country:US
Mailing Address - Phone:402-659-0642
Mailing Address - Fax:
Practice Address - Street 1:220 ESSIE DAVISON DR
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2915
Practice Address - Country:US
Practice Address - Phone:712-542-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA066623363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0442715Medicaid
P00126757OtherRR MEDICARE IOWA
NE100251147-00Medicaid
10336OtherMIDLANDS CHOICE
IAS84927Medicare UPIN
P00126757OtherRR MEDICARE IOWA