MEDICARE: LADONNA JENIQUE GLADNEY NDTR, CPT

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	136A00000X	Registered Dietetic Technician		WI

General Provider Information

NPI Number	:	1912673674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LADONNA JENIQUE GLADNEY NDTR, CPT

Provider Business Mailing Address
First Line	:	3332 N 78TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3920
Country	:	US
Telephone Number	:	866-252-2989
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 E CLARKE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2925
Country	:	US
Telephone Number	:	866-252-2989
Fax Number	:

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

Provider Enumeration Date	:	08/20/2021
Last Update Date	:	11/19/2021

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