Provider Demographics
NPI:1184698557
Name:WULF, JUDITH A (ANP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:WULF
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:A
Other - Last Name:GREENWOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1309 - 8170 33RD AVE S
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-7900
Mailing Address - Fax:651-254-7904
Practice Address - Street 1:401 PHALEN BOULEVARD
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7900
Practice Address - Fax:651-254-7904
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP2302363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN04-10205OtherMEDICA
MN1184698557Medicaid
WI43917100Medicaid
P07186Medicare UPIN
MN1184698557Medicaid