Provider Demographics
NPI:1780817759
Name:CARLSON, RENEE M (NP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:CARLSON
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 1:3004 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-8793
Mailing Address - Country:US
Mailing Address - Phone:715-514-2827
Mailing Address - Fax:
Practice Address - Street 1:3004 GOLF RD STE 103
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-8794
Practice Address - Country:US
Practice Address - Phone:715-514-2827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3808363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0202700560Medicare NSC