Provider Demographics
NPI:1043057003
Name:WOLFE, WESLEY
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:WOLFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 GREYSTONE SQ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3589
Mailing Address - Country:US
Mailing Address - Phone:731-664-7581
Mailing Address - Fax:731-660-8510
Practice Address - Street 1:3004 GREYSTONE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3589
Practice Address - Country:US
Practice Address - Phone:731-664-7581
Practice Address - Fax:731-660-8510
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39671171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty