Provider Demographics
NPI:1427247709
Name:RETZER, CAROL M (LPN)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:M
Last Name:RETZER
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 1:4555 W SCHROEDER DR STE 185
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1494
Mailing Address - Country:US
Mailing Address - Phone:414-586-0222
Mailing Address - Fax:414-586-0236
Practice Address - Street 1:4555 W SCHROEDER DR STE 185
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-1494
Practice Address - Country:US
Practice Address - Phone:414-586-0222
Practice Address - Fax:414-586-0236
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27752-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42017500Medicaid