Healthcare Provider Details

I. General information

NPI: 1770287732
Provider Name (Legal Business Name): MACEY KIERA JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 W FOND DU LAC AVE
MILWAUKEE WI
53216-1382
US

IV. Provider business mailing address

1855 N WATER ST UNIT 316
MILWAUKEE WI
53202-5121
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-8900
  • Fax: 414-277-8982
Mailing address:
  • Phone: 414-271-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number85577-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: