Basic Information
| Provider Information | |||||||||
| NPI: | 1184076713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRELL | ||||||||
| FirstName: | ANNIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 WEST CAPITOL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53206 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | 4147276329 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | 4147276329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2016 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 7040-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7040-33 | 01 | WI | WI LICENSE | OTHER |