Provider Demographics
NPI:1619039344
Name:HARRIS, CARRIE LYNN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYNN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:LYNN
Other - Last Name:SELIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1032 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1608
Practice Address - Country:US
Practice Address - Phone:262-673-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI125211-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44359600Medicaid