Healthcare Provider Details

I. General information

NPI: 1366606618
Provider Name (Legal Business Name): CAROL ANN MERTINS APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 8TH ST
WATERTOWN WI
53094-4730
US

IV. Provider business mailing address

415 S 8TH ST
WATERTOWN WI
53094-4730
US

V. Phone/Fax

Practice location:
  • Phone: 920-206-7797
  • Fax: 920-206-0870
Mailing address:
  • Phone: 920-206-7797
  • Fax: 920-206-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number3055-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3055-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: