Provider Demographics
NPI:1225784465
Name:DEADWYLER, LONIQUA KILONDRA
Entity Type:Individual
Prefix:MS
First Name:LONIQUA
Middle Name:KILONDRA
Last Name:DEADWYLER
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 1:4300 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1634
Mailing Address - Country:US
Mailing Address - Phone:414-841-1406
Mailing Address - Fax:
Practice Address - Street 1:4300 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1634
Practice Address - Country:US
Practice Address - Phone:414-841-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060728600172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver