Provider Demographics
NPI:1871743138
Name:HERZBERG, CAROL LYNN (APNP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYNN
Last Name:HERZBERG
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S89W23120 KING PKWY
Mailing Address - Street 2:
Mailing Address - City:BIG BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53103-9720
Mailing Address - Country:US
Mailing Address - Phone:262-662-4824
Mailing Address - Fax:
Practice Address - Street 1:S89W23120 KING PKWY
Practice Address - Street 2:
Practice Address - City:BIG BEND
Practice Address - State:WI
Practice Address - Zip Code:53103-9720
Practice Address - Country:US
Practice Address - Phone:262-662-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI399-033364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39734300Medicaid