Provider Demographics
NPI:1659569929
Name:MYLES, SHALONDA NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:SHALONDA
Middle Name:NICOLE
Last Name:MYLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4110
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:7384 N 60TH ST
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-4602
Practice Address - Country:US
Practice Address - Phone:414-737-4774
Practice Address - Fax:414-435-3152
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9835363L00000X
WI142072-030163W00000X
WI9835-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659569929Medicaid