Basic Information
| Provider Information | |||||||||
| NPI: | 1972144376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | MADELINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1343 N 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530901813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206551038 | ||||||||
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| Practice Location | |||||||||
| Address1: | 945 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142196777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 9666-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100094193 | 05 | WI | MEDICAID |