Provider Demographics
NPI:1295433282
Name:WOLFE DAVIS, KIMBERLY (DNP,APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WOLFE DAVIS
Suffix:
Gender:F
Credentials:DNP,APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 S DELANO ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5480
Practice Address - Country:US
Practice Address - Phone:810-488-8390
Practice Address - Fax:810-985-5543
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704346834363L00000X, 363L00000X
KY1135976163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse