Provider Demographics
NPI:1891158564
Name:CARLSON, WENDY MARIE (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:MARIE
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:21 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-2324
Mailing Address - Country:US
Mailing Address - Phone:774-501-1440
Mailing Address - Fax:508-967-7304
Practice Address - Street 1:21 SHORE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MA
Practice Address - Zip Code:02779-2324
Practice Address - Country:US
Practice Address - Phone:774-501-1440
Practice Address - Fax:508-967-7304
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI48702163W00000X
MA230033163W00000X
RIAPRN01440363LP0808X
MARN230033363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400325789Medicaid
MARN230033OtherAPRN
RIAPRN01440OtherAPRN
MAMC4398120OtherCONTROLLED SUBSTANCE REGISTRATION
RICAPRN01440OtherRHODE ISLAND CONTROLLED SUBSTANCE REGISTRY