Provider Demographics
NPI:1871083683
Name:WOLFRUM, EMILY KATHERINE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:KATHERINE
Last Name:WOLFRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:KATHERINE
Other - Last Name:SKELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24116 MEADOWBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3008
Mailing Address - Country:US
Mailing Address - Phone:407-485-9541
Mailing Address - Fax:
Practice Address - Street 1:17900 23 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1161
Practice Address - Country:US
Practice Address - Phone:586-868-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289427363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care