Provider Demographics
NPI:1053986042
Name:ALLEN, KEANA M
Entity type:Individual
Prefix:
First Name:KEANA
Middle Name:M
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 N 58TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2238
Mailing Address - Country:US
Mailing Address - Phone:414-323-3554
Mailing Address - Fax:414-269-9562
Practice Address - Street 1:2619 N 58TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2238
Practice Address - Country:US
Practice Address - Phone:414-323-3554
Practice Address - Fax:414-269-9562
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty