Healthcare Provider Details

I. General information

NPI: 1023776416
Provider Name (Legal Business Name): CARRIE L MOENK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVE DR
OSHKOSH WI
54904
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-5626
  • Fax:
Mailing address:
  • Phone: 203-035-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number170094-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: