Provider Demographics
NPI:1184076713
Name:CARRELL, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:CARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 WEST CAPITOL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206
Mailing Address - Country:UM
Mailing Address - Phone:414-727-6320
Mailing Address - Fax:414-727-6329
Practice Address - Street 1:210 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1123
Practice Address - Country:US
Practice Address - Phone:414-727-6320
Practice Address - Fax:414-727-6329
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7040-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7040-33OtherWI LICENSE