Provider Demographics
NPI:1740660547
Name:RAY-WOLFE, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:RAY-WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W RAMPART ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8846
Mailing Address - Country:US
Mailing Address - Phone:317-398-0121
Mailing Address - Fax:317-398-1866
Practice Address - Street 1:30 W RAMPART ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8846
Practice Address - Country:US
Practice Address - Phone:317-398-0121
Practice Address - Fax:317-398-1866
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005505A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily