Provider Demographics
NPI:1982979712
Name:WOLF, NICOLE L (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:WOLF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:RITTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5943 STADIUM DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260077363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner