Healthcare Provider Details

I. General information

NPI: 1952052763
Provider Name (Legal Business Name): DONNAFIT4LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 N 78TH ST
MILWAUKEE WI
53222-3920
US

IV. Provider business mailing address

3332 N 78TH ST
MILWAUKEE WI
53222-3920
US

V. Phone/Fax

Practice location:
  • Phone: 414-866-2522
  • Fax:
Mailing address:
  • Phone: 414-866-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LADONNA GLADNEY
Title or Position: OWNER- AND PROVIDER
Credential: NDTR, CPT
Phone: 866-252-2989