MEDICARE: KENYETTE B BLUE

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	172V00000X	Community Health Worker
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1659024628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYETTE B BLUE

Provider Business Mailing Address
First Line	:	4230 N OAKLAND AVE # 189
Second Line	:
City	:	SHOREWOOD
State	:	WI
Zip	:	53211-2042
Country	:	US
Telephone Number	:	414-331-0382
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 W NORTH AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1237
Country	:	US
Telephone Number	:	414-510-7068
Fax Number	:

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

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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Directions to “ KENYETTE B BLUE ” Practice Location

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