Healthcare Provider Details

I. General information

NPI: 1215661061
Provider Name (Legal Business Name): NICOSHA SHANAE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 W NATIONAL AVE APT 140
MILWAUKEE WI
53204-1742
US

IV. Provider business mailing address

704 W NATIONAL AVE APT 140
MILWAUKEE WI
53204-1742
US

V. Phone/Fax

Practice location:
  • Phone: 414-243-6647
  • Fax:
Mailing address:
  • Phone: 414-243-6647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: