Provider Demographics
NPI:1447208723
Name:CARLSON, KATHLEEN SUE (LPN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 W JERELYN PL
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2273
Mailing Address - Country:US
Mailing Address - Phone:414-321-3191
Mailing Address - Fax:
Practice Address - Street 1:5224 W JERELYN PL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-2273
Practice Address - Country:US
Practice Address - Phone:414-321-3191
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12282-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39899500Medicaid