Provider Demographics
NPI:1669650107
Name:RAFFERTY, CAROL A (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23400
Mailing Address - Street 2:THE NEURO TEAM
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-3400
Mailing Address - Country:US
Mailing Address - Phone:920-433-7995
Mailing Address - Fax:920-433-3458
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:THE NEURO TEAM
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-433-7995
Practice Address - Fax:920-433-3458
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI472-33363L00000X
WI65003163W00000X
WI472033363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43825200Medicaid
WI43825200Medicaid