Healthcare Provider Details

I. General information

NPI: 1336491646
Provider Name (Legal Business Name): MHARAJOY S KOBINAH APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MHARAJOY G SISON APNP

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 N PORT WASHINGTON RD SUITE 325
GLENDALE WI
53212-1004
US

IV. Provider business mailing address

PO BOX 639
THIENSVILLE WI
53092-0639
US

V. Phone/Fax

Practice location:
  • Phone: 414-269-8282
  • Fax: 414-269-8280
Mailing address:
  • Phone: 414-247-9005
  • Fax: 414-247-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6717
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: