Provider Demographics
NPI:1629445077
Name:MANLICK, CARRIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
Last Name:MANLICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:W296N2124 GLEN COVE RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4833
Mailing Address - Country:US
Mailing Address - Phone:262-695-2287
Mailing Address - Fax:
Practice Address - Street 1:W296N2124 GLEN COVE RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4833
Practice Address - Country:US
Practice Address - Phone:262-695-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI87293163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse