Provider Demographics
NPI:1720172745
Name:KAKO, PENINNAH M (APNP)
Entity Type:Individual
Prefix:
First Name:PENINNAH
Middle Name:M
Last Name:KAKO
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9619 BEACHWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224
Mailing Address - Country:US
Mailing Address - Phone:414-353-8788
Mailing Address - Fax:
Practice Address - Street 1:12601 W HAMPTON AVENUE
Practice Address - Street 2:SUITE 100A
Practice Address - City:BUTLER
Practice Address - State:WI
Practice Address - Zip Code:53007
Practice Address - Country:US
Practice Address - Phone:262-373-1869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1806-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43930800Medicaid