Provider Demographics
NPI:1235818980
Name:GIFTED DIVERSITY HANDS,LLC
Entity Type:Organization
Organization Name:GIFTED DIVERSITY HANDS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAQUILLA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HANNON
Authorized Official - Suffix:
Authorized Official - Credentials:CARE PROVIDER
Authorized Official - Phone:414-552-3291
Mailing Address - Street 1:3940 W LISBON AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1883
Mailing Address - Country:US
Mailing Address - Phone:414-552-3291
Mailing Address - Fax:262-999-0150
Practice Address - Street 1:1728 W WRIGHT ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2043
Practice Address - Country:US
Practice Address - Phone:262-696-9711
Practice Address - Fax:262-999-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17571Medicaid