Provider Demographics
NPI:1356629851
Name:ROBERTSON, KENYA R (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:R
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:KENYA
Other - Middle Name:R
Other - Last Name:BANYARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:4573 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6005
Mailing Address - Country:US
Mailing Address - Phone:414-698-3245
Mailing Address - Fax:
Practice Address - Street 1:4573 N 29TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6005
Practice Address - Country:US
Practice Address - Phone:414-698-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5717-33363LP0808X, 363LF0000X
WI147235-30163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice