Provider Demographics
NPI:1285725291
Name:WOLF, KIMBERLY M (PHD, PMHCNS-BC APRN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:WOLF
Suffix:
Gender:F
Credentials:PHD, PMHCNS-BC APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-2291
Mailing Address - Fax:612-904-4477
Practice Address - Street 1:701 PARK AVE # O8
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-2291
Practice Address - Fax:612-904-4477
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0012364SP0809X
MNR1558205364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDQ23492Medicare UPIN
ND24812Medicare PIN