Healthcare Provider Details

I. General information

NPI: 1962321240
Provider Name (Legal Business Name): JESTUS LARENZA RAMENE FAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 N 56TH ST
MILWAUKEE WI
53210-1526
US

IV. Provider business mailing address

2803 N 56TH ST
MILWAUKEE WI
53210-1526
US

V. Phone/Fax

Practice location:
  • Phone: 414-484-8755
  • Fax:
Mailing address:
  • Phone: 414-484-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: