Healthcare Provider Details

I. General information

NPI: 1780255869
Provider Name (Legal Business Name): CODDLE CARE PNCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W BROWN DEER RD STE 105
BROWN DEER WI
53223-2263
US

IV. Provider business mailing address

6051 W BROWN DEER RD STE 105
BROWN DEER WI
53223-2263
US

V. Phone/Fax

Practice location:
  • Phone: 414-446-5578
  • Fax: 414-446-5855
Mailing address:
  • Phone: 414-446-5578
  • Fax: 414-446-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: TAMARA JOHNSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 414-446-5578