MEDICARE: CAROL WEICKARDT RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0071902-030	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255517017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL WEICKARDT RN

Provider Business Mailing Address
First Line	:	W328 S1421 N FOREST HILL CT
Second Line	:
City	:	DELAFIELD
State	:	WI
Zip	:	53018-3362
Country	:	US
Telephone Number	:	262-968-9588
Fax Number	:

Provider Business Practice Location Address
First Line	:	W328 S1421 N FOREST HILL CT
Second Line	:
City	:	DELAFIELD
State	:	WI
Zip	:	53018-3362
Country	:	US
Telephone Number	:	262-968-9588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/11/2008

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