Healthcare Provider Details

I. General information

NPI: 1598932527
Provider Name (Legal Business Name): SHIRLEY TEMPLE GLADNEY REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 N 70TH ST
MILWAUKEE WI
53218-4847
US

IV. Provider business mailing address

4676 N 70TH ST
MILWAUKEE WI
53218-4847
US

V. Phone/Fax

Practice location:
  • Phone: 414-462-0802
  • Fax:
Mailing address:
  • Phone: 414-462-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91195-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number91195-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: