Healthcare Provider Details

I. General information

NPI: 1912673674
Provider Name (Legal Business Name): LADONNA JENIQUE GLADNEY NDTR, CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 E CLARKE ST
MILWAUKEE WI
53212-2925
US

IV. Provider business mailing address

3332 N 78TH ST
MILWAUKEE WI
53222-3920
US

V. Phone/Fax

Practice location:
  • Phone: 866-252-2989
  • Fax:
Mailing address:
  • Phone: 866-252-2989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: