Provider Demographics
NPI:1871992735
Name:MUSHA, CARLY
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:MUSHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 W WELLS ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3240
Mailing Address - Country:US
Mailing Address - Phone:414-852-5879
Mailing Address - Fax:
Practice Address - Street 1:5816 W WELLS ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3240
Practice Address - Country:US
Practice Address - Phone:414-852-5879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156212-30163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health