Provider Demographics
NPI:1760244495
Name:BAQUET, SHANICE L
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:L
Last Name:BAQUET
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 1:2656 N TEUTONIA AVE UNIT 6566
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-3421
Mailing Address - Country:US
Mailing Address - Phone:262-457-9815
Mailing Address - Fax:
Practice Address - Street 1:2803 N TEUTONIA AVE UNIT B
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2661
Practice Address - Country:US
Practice Address - Phone:262-457-9815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker