Provider Demographics
NPI:1952559056
Name:DICARLO, HOLLY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:DICARLO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S62 W24372 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9616
Mailing Address - Country:US
Mailing Address - Phone:262-549-3266
Mailing Address - Fax:
Practice Address - Street 1:S62W24372 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-9616
Practice Address - Country:US
Practice Address - Phone:262-549-3266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11528-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35064800Medicaid