Provider Demographics
NPI:1356300941
Name:CARBAJAL, ANN MARIE (HIS)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MARIE
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 W HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1904
Mailing Address - Country:US
Mailing Address - Phone:414-312-7111
Mailing Address - Fax:414-321-7258
Practice Address - Street 1:5913 W HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-1904
Practice Address - Country:US
Practice Address - Phone:414-312-7111
Practice Address - Fax:414-321-7258
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI599237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42818700Medicaid