Healthcare Provider Details

I. General information

NPI: 1578474730
Provider Name (Legal Business Name): KHADIJA'S KOZY KORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8320 W LISBON AVE
MILWAUKEE WI
53222-3866
US

IV. Provider business mailing address

8320 W LISBON AVE
MILWAUKEE WI
53222-3866
US

V. Phone/Fax

Practice location:
  • Phone: 414-808-0081
  • Fax: 262-364-3319
Mailing address:
  • Phone: 414-808-0081
  • Fax: 262-364-3319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: RAQIBA MALIK
Title or Position: CEO
Credential:
Phone: 414-301-0020