MEDICARE: MS. LAKISHA REFAY CLEMONS RN

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	163W00000X	Registered Nurse		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38318700	OTHER	WI	PROVIDER NUMBER

General Provider Information

NPI Number	:	1730352295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAKISHA REFAY CLEMONS RN

Provider Business Mailing Address
First Line	:	4037 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1811
Country	:	US
Telephone Number	:	414-461-0418
Fax Number	:

Provider Business Practice Location Address
First Line	:	4037 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1811
Country	:	US
Telephone Number	:	414-461-0418
Fax Number	:

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

Provider Enumeration Date	:	04/05/2008
Last Update Date	:	04/05/2008

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