Healthcare Provider Details

I. General information

NPI: 1891158564
Provider Name (Legal Business Name): WENDY MARIE CARLSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WENDY MARIE NICHOLS RN

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SHORE RD
BERKLEY MA
02779-2324
US

IV. Provider business mailing address

21 SHORE RD
BERKLEY MA
02779-2324
US

V. Phone/Fax

Practice location:
  • Phone: 774-501-1440
  • Fax: 508-967-7304
Mailing address:
  • Phone: 774-501-1440
  • Fax: 508-967-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number48702
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number230033
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN01440
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN230033
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: