Provider Demographics
NPI:1740328582
Name:LEE, CARRIE M (CPNP)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:M
Last Name:LEE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:M
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC ALLERGY AND IMMUNOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6840
Mailing Address - Fax:414-266-6437
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC ALLERGY AND IMMUNOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6840
Practice Address - Fax:414-266-6437
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127935363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740328582Medicaid
WI1740328582Medicaid