Provider Demographics
NPI:1841373404
Name:WOLF, COURTNEY E (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:WOLF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:COURTNEY
Other - Middle Name:E
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:1500 N RITTER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3027
Practice Address - Country:US
Practice Address - Phone:317-274-4779
Practice Address - Fax:317-948-9806
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28154359363LN0000X
IN71002062A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01221391OtherRR MEDICARE PTAN
IN000000589162OtherANTHEM PROVIDER NUMBER
IN200515470Medicaid
IN200515470Medicaid
IN266180216Medicare PIN