Healthcare Provider Details

I. General information

NPI: 1457764524
Provider Name (Legal Business Name): GAIL JEAN DENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 N MAIN ST APT 324
RACINE WI
53402-2878
US

IV. Provider business mailing address

4240 N MAIN ST APT 324
RACINE WI
53402-2878
US

V. Phone/Fax

Practice location:
  • Phone: 262-886-5296
  • Fax: 262-886-5296
Mailing address:
  • Phone: 262-886-5296
  • Fax: 262-886-5296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number46-5667326
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: