Provider Demographics
NPI:1770660227
Name:CHRISTIE, CAROL (CRNA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CHRISTIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 S UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-887-7181
Mailing Address - Fax:920-887-3422
Practice Address - Street 1:707 S UNIVERSITY
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-7181
Practice Address - Fax:920-887-3422
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI041393367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43335100Medicaid
WI43335100Medicaid
WI211040025Medicare ID - Type Unspecified