Provider Demographics
NPI:1063685428
Name:OTTOSEN, CARRIE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:OTTOSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6055 CUBA VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-9603
Mailing Address - Country:US
Mailing Address - Phone:608-850-5770
Mailing Address - Fax:
Practice Address - Street 1:6055 CUBA VALLEY RD
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-9603
Practice Address - Country:US
Practice Address - Phone:608-850-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38268300Medicaid