Provider Demographics
NPI:1679655104
Name:WILSON, CARRIE H (RN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:H
Last Name:WILSON
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 1:2625 BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-9126
Mailing Address - Country:US
Mailing Address - Phone:608-574-5763
Mailing Address - Fax:
Practice Address - Street 1:2625 BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-9126
Practice Address - Country:US
Practice Address - Phone:608-574-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128876030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38210300Medicaid