Healthcare Provider Details

I. General information

NPI: 1245270263
Provider Name (Legal Business Name): CAROLYN ANNE BAKER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 KALFAHS ST
NEENAH WI
54956-4110
US

IV. Provider business mailing address

N 2955 BIRCHWOOD DR
CAMPBELLSPORT WI
53010-1858
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-0176
  • Fax:
Mailing address:
  • Phone: 920-533-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number16641031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: