Healthcare Provider Details

I. General information

NPI: 1356629851
Provider Name (Legal Business Name): KENYA R ROBERTSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENYA R BANYARD FNP-BC

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4573 N 29TH ST
MILWAUKEE WI
53209-6005
US

IV. Provider business mailing address

4573 N 29TH ST
MILWAUKEE WI
53209-6005
US

V. Phone/Fax

Practice location:
  • Phone: 414-698-3245
  • Fax:
Mailing address:
  • Phone: 414-698-3245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5717-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number147235-30
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5717-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: