Provider Demographics
NPI:1902085996
Name:NEISSEN, CAROL A (LPN)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:NEISSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8093 TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115
Mailing Address - Country:US
Mailing Address - Phone:608-883-2344
Mailing Address - Fax:
Practice Address - Street 1:122 EAGLE LAKE AVE
Practice Address - Street 2:
Practice Address - City:MUKWANAGO
Practice Address - State:WI
Practice Address - Zip Code:53149
Practice Address - Country:US
Practice Address - Phone:262-363-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35038600Medicaid