Basic Information
| Provider Information | |||||||||
| NPI: | 1255683850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRZEWIECKI ANDERSON | ||||||||
| OtherFirstName: | CARMEN | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457210 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S VANBUREN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204337488 | ||||||||
| FaxNumber: | 9204337439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5082-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5082-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.