Provider Demographics
NPI:1053926949
Name:WORDEN, CARLY (NP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:WORDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:PICKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-551-2700
Mailing Address - Fax:
Practice Address - Street 1:2707 15TH PL
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4947
Practice Address - Country:US
Practice Address - Phone:262-551-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10299-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100104069Medicaid