Healthcare Provider Details

I. General information

NPI: 1689339293
Provider Name (Legal Business Name): LA SHANDRA NICHELLE YOUNG REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

5731 W ROOSEVELT DR
MILWAUKEE WI
53216-3155
US

IV. Provider business mailing address

PO BOX 76068
MILWAUKEE WI
53216-7668
US

V. Phone/Fax

Practice location:
  • Phone: 414-403-1611
  • Fax:
Mailing address:
  • Phone: 414-403-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number139406
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: