MEDICARE: MS. LONIQUA KILONDRA DEADWYLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	060728600	GA

General Provider Information

NPI Number	:	1225784465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LONIQUA KILONDRA DEADWYLER

Provider Business Mailing Address
First Line	:	4300 N 92ND ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1634
Country	:	US
Telephone Number	:	414-841-1406
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 N 92ND ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1634
Country	:	US
Telephone Number	:	414-841-1406
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2022
Last Update Date	:	02/25/2022

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