Provider Demographics
NPI:1194017194
Name:CARROLL, ANGELA SUELINE (RN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:SUELINE
Last Name:CARROLL
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 1:6228 W KAUL AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-1527
Mailing Address - Country:US
Mailing Address - Phone:262-344-4002
Mailing Address - Fax:
Practice Address - Street 1:6228 W KAUL AVE APT 1
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-1527
Practice Address - Country:US
Practice Address - Phone:262-344-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI155143-030313M00000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness