Healthcare Provider Details

I. General information

NPI: 1053986042
Provider Name (Legal Business Name): KEANA M ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 N 58TH ST
MILWAUKEE WI
53210-2238
US

IV. Provider business mailing address

2619 N 58TH ST
MILWAUKEE WI
53210-2238
US

V. Phone/Fax

Practice location:
  • Phone: 414-323-3554
  • Fax: 414-269-9562
Mailing address:
  • Phone: 414-323-3554
  • Fax: 414-269-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: