Provider Demographics
NPI:1710293204
Name:BAKER, CARLY JEAN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 TILSON ST E
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1213
Mailing Address - Country:US
Mailing Address - Phone:608-792-2646
Mailing Address - Fax:
Practice Address - Street 1:510 N COURT ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1708
Practice Address - Country:US
Practice Address - Phone:608-633-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302971-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse