Healthcare Provider Details

I. General information

NPI: 1558589887
Provider Name (Legal Business Name): SHALONDA BOOTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N 66TH ST
MILWAUKEE WI
53218-4820
US

IV. Provider business mailing address

4646 N 66TH ST
MILWAUKEE WI
53218-4820
US

V. Phone/Fax

Practice location:
  • Phone: 414-702-8339
  • Fax:
Mailing address:
  • Phone: 414-702-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateWI

VIII. Authorized Official

Name: MS. SHALONDA NICOLE BOOTH
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 414-702-8339