Healthcare Provider Details

I. General information

NPI: 1659024628
Provider Name (Legal Business Name): KENYETTE B BLUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 W NORTH AVE
MILWAUKEE WI
53205-1237
US

IV. Provider business mailing address

4230 N OAKLAND AVE # 189
SHOREWOOD WI
53211-2042
US

V. Phone/Fax

Practice location:
  • Phone: 414-510-7068
  • Fax:
Mailing address:
  • Phone: 414-331-0382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: