Provider Demographics
NPI:1952052763
Name:DONNAFIT4LIFE LLC
Entity Type:Organization
Organization Name:DONNAFIT4LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER- AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:
Authorized Official - Credentials:NDTR, CPT
Authorized Official - Phone:866-252-2989
Mailing Address - Street 1:3332 N 78TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3920
Mailing Address - Country:US
Mailing Address - Phone:414-866-2522
Mailing Address - Fax:
Practice Address - Street 1:3332 N 78TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3920
Practice Address - Country:US
Practice Address - Phone:414-866-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912673674Medicaid