Healthcare Provider Details

I. General information

NPI: 1114633443
Provider Name (Legal Business Name): MCKAYLA Q THARP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY STE 980
MILWAUKEE WI
53215-3689
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-5111
  • Fax: 414-384-5040
Mailing address:
  • Phone: 414-384-5111
  • Fax: 414-384-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13303
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: