Healthcare Provider Details

I. General information

NPI: 1770879751
Provider Name (Legal Business Name): MARIAN V. CARLSON L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 SEMINOLE TRL
SAINT GERMAIN WI
54558-9032
US

IV. Provider business mailing address

W8164 STATE HIGHWAY 47
ANTIGO WI
54409-9042
US

V. Phone/Fax

Practice location:
  • Phone: 715-542-4461
  • Fax:
Mailing address:
  • Phone: 715-219-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number22788
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: