| NPI |
1669054086 |
The telephone number associated with the location address of the provider being identified. |
| Entity Type Code |
1 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider Last Name Legal Name |
WOLF |
The date that a record was last updated or changed. |
| Provider First Name |
LILY |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Provider Middle Name |
KATHLEEN |
The middle name of the provider, if the provider
is an individual. |
| Provider Name Prefix Text |
DR. |
The middle name of the authorized official. |
| Provider Credential Text |
MD |
The title or position of the authorized official. |
| Provider First Line Business Practice Location Address |
635 BARNHILL DRIVE |
The 10-position telephone number of the authorized official. |
| Provider Second Line Business Practice Location Address |
VAN NUYS MEDICAL SCIENCE BUILDING 116 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Business Practice Location Address City Name |
INDIANAPOLIS |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider Business Practice Location Address State Name |
IN |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Postal Code |
462025126 |
|
| Provider Business Practice Location Address Country Code If outside U S |
US |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Provider Business Practice Location Address Telephone Number |
3172748282 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Provider Enumeration Date |
4/26/2021 |
|
| Last Update Date |
6/20/2022 |
|
| Provider Gender Code |
F |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Healthcare Provider Taxonomy Code 1 |
390200000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| NPI Certification Date |
6/20/2022 |
|