Provider Demographics
NPI:1932704277
Name:WOLF, KELLY ANN (BSPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WOLF
Suffix:
Gender:F
Credentials:BSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 SW COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-9607
Mailing Address - Country:US
Mailing Address - Phone:319-404-0833
Mailing Address - Fax:
Practice Address - Street 1:2925 SW COUNTRY LN
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9607
Practice Address - Country:US
Practice Address - Phone:319-404-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist