Provider Demographics
NPI:1407420177
Name:COSGROVE, CARRIE LEE (RN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEE
Last Name:COSGROVE
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 1:5071 W COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2012
Mailing Address - Country:US
Mailing Address - Phone:141-465-1803
Mailing Address - Fax:
Practice Address - Street 1:1610 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:414-651-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129441163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty