Provider Demographics
NPI:1912415068
Name:WOLF, ERICA JANE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:JANE
Last Name:WOLF
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 1:3737 SOUTHERN BLVD STE 4200
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-0135
Mailing Address - Country:US
Mailing Address - Phone:937-294-1489
Mailing Address - Fax:937-294-7999
Practice Address - Street 1:3101 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3014
Practice Address - Country:US
Practice Address - Phone:859-802-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.425121390200000X
OHAPRN.CNP.024338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program