Provider Demographics
NPI:1073915419
Name:TENNER, MYLAI
Entity Type:Individual
Prefix:
First Name:MYLAI
Middle Name:
Last Name:TENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2404
Mailing Address - Country:US
Mailing Address - Phone:414-312-7729
Mailing Address - Fax:262-364-2044
Practice Address - Street 1:2838 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2404
Practice Address - Country:US
Practice Address - Phone:414-312-7729
Practice Address - Fax:262-364-2044
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider