MEDICARE: MRS. LATEESAH MONE LOVE-MINOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide		WI

General Provider Information

NPI Number	:	1154034023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATEESAH MONE LOVE-MINOR

Provider Business Mailing Address
First Line	:	2936 N 77TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-5016
Country	:	US
Telephone Number	:	262-282-8611
Fax Number	:

Provider Business Practice Location Address
First Line	:	2936 N 77TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-5016
Country	:	US
Telephone Number	:	262-282-8611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2023
Last Update Date	:	01/05/2023

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