Healthcare Provider Details

I. General information

NPI: 1407420177
Provider Name (Legal Business Name): CARRIE LEE COSGROVE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 MILLER PARK WAY
WEST MILWAUKEE WI
53214-3604
US

IV. Provider business mailing address

5071 W COLONIAL CT
GREENFIELD WI
53220-2012
US

V. Phone/Fax

Practice location:
  • Phone: 414-651-8033
  • Fax:
Mailing address:
  • Phone: 141-465-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number129441
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: