Provider Demographics
NPI:1316152010
Name:WOLFE FAMILY MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:WOLFE FAMILY MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-647-0900
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:203 EAST WALNUT STREET
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-0069
Mailing Address - Country:US
Mailing Address - Phone:662-647-0900
Mailing Address - Fax:662-647-0938
Practice Address - Street 1:203 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921
Practice Address - Country:US
Practice Address - Phone:662-647-0900
Practice Address - Fax:662-647-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08184344Medicaid
MS08184344Medicaid